three in four ask for information about their desti- ... health information during travel are general practi- ... Travelers' Compliance to Prophylaxis and Behavior.
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Travelers’ Compliance to Prophylactic Measures and Behavior During Stay Abroad: Results of a Retrospective Study of Subjects Returning to a Travel Medicine Center in Italy Enrico Laverone, MD,* Sara Boccalini, ScBiol,† Angela Bechini, ScBiol,† Simona Belli, Health Operator,* Maria Grazia Santini, MD,* Simonetta Baretti, MD,* Giuseppe Circelli, MD,* Felicina Taras, Health Operator,* Serena Banchi, MD,† and Paolo Bonanni, MD† *Centre for Travel and Migration Medicine, Local Health Unit of Florence, Italy; †Department of Public Health, University of Florence, Italy DOI: 10.1111/j.1708-8305.2006.00068.x
Background. Many sources of health advice are consulted by travelers, but in Europe, only 35% go to a travel clinic. Travel to countries outside Europe increases daily, and from 2001 to 2004, there was a marked increase in the number of travelers from the Florentine area crossing the borders (+18.0%), taking a plane (+81.4% of international travelers in Pisa airport), and applying to the Centre of Travel and Migration Medicine (CTMM) (+96%). Methods. An anonymous survey was carried out at CTMM among those travelers returning to complete vaccinations for which the first dose had been given before going abroad. The survey included questions on vaccination status, adherence to recommended antimalaria prophylaxis, occurrence of other health problems, and food and drink consumption. Results. The study population (which represents a “best case scenario”) was composed of 1,237 subjects and had a very high compliance to the proposed questionnaire (95%). Approximately 55% of travelers took malaria chemoprophylactic measures, and 88% of them followed the indications given. Approximately 28% reported one or more secondary effects following antimalarial medication, and approximately 69% reported constant attention regarding safe consumption of food and drinks. Notwithstanding these measures, 236 cases of travelers’ diarrhea were reported. Conclusions. Our results are conditioned by the self-selection of the study population (those who seek advice are likely to follow it through). However, since no certainty exists about other sources of health advice for the remainder of the traveler population in our region, both the importance of counseling offered by travel clinics as well as the recommendation to the ever-increasing number of travelers to consult these clinics are stressed.
T
ravel to countries outside Europe is steadily increasing. However, the knowledge of travelers of the potential risks posed by different climates and/or poor hygiene and bad health conditions has not kept the same pace.1–3 Nevertheless, over the past years, there has been a growing perception of the need for health protection during travel, which has prompted travelers to seek advice on measures to take against several illnesses, notably infectious diseases. Corresponding Author: Paolo Bonanni, MD, Department of Public Health, University of Florence, Viale Morgagni 48, I-50134 Florence, Italy. E-mail: paolo. bonanni@unifi.it
According to a recent European study carried out on travelers departing from several airports, three in four ask for information about their destinations but only half seek advice concerning health during travel. The main sources consulted for health information during travel are general practitioners (57.4%), travel clinics (35.3%), travel agents (30.0%), family and friends (27.8%), Internet (24.0%), books/magazines (22.5%), and pharmacists (20.1%). Of these, travel clinics > general practitioners > occupational physicians are considered more reliable than other sources (Internet > family and friends > pharmacists > travel agents > books).4,5 These sources should be consulted well in advance, although at present last minute travel is an
© 2006 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine, Volume 13, Issue 6, 2006, 338–344
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Travelers’ Compliance to Prophylaxis and Behavior ever-increasing phenomenon: a high number of travelers (40%) only plan their journey 1 month before departure and 23% only 2 weeks before, consequently often hindering or even impeding the possibility to adopt correct preventive measures.4,5 Timely preparation is especially important for long-term travel to rural destinations. All the above sources are available for consultation by Italian travelers. In addition, in Italy, travel agents are obliged by law to advise their clients on the health implications of travel and on all the preventive measures to adopt for the respective destinations.6 Over the past few years, the number of outgoing travelers has steadily increased in our region: Tuscans crossing the border rose by 5.7% from 2001– 2002 to 2003–2004, while in the same period, the increase of travelers living in the area of Florence was 18.0%.7 Concerning air traffic, two airports are available for Florence: the small local airport and Pisa International Airport, with a bigger volume of traffic and destinations. The total number of passengers using Florence airport increased only by 0.4% between 2001 and 2004, while at Pisa airport international passengers increased by 81.4% between 2001 and 2003 (data related to 2004 not yet available).8,9 Accordingly, the number of travelers addressing the Centre of Travel and Migration Medicine (CTMM) of the Local Health Unit of Florence increased from 6,749 in 2001–2002 to 13,216 in 2003–2004. They visited the travel clinic to have the recommended vaccinations, to get advice on antimalaria prophylaxis, and for consultation also on other health-related aspects (climatic change, hygienic conditions, food, information on local diseases, etc). The aim of this descriptive study was to see how the investigated travelers behaved when abroad and thereby to assess the effectiveness of counseling: to find out whether the advice given on antimalaria prophylaxis was carried out, whether the travelers experienced adverse effects due to antimalaria medication or following immunization, to what extent the travelers complied with the advice offered regarding the various aspects of travel safety. The inquiry was also intended to evaluate the usefulness of counseling in relation to the journey undertaken (risk for each visited country, itinerary, type of accommodation, risk of malaria, behavior relating to food consumption etc.). Methods An anonymous survey in a post-travel situation was carried out from January 1, 2003, to December 31,
2004, at the Florence CTMM, among all travelers who had already completed their journey for which they had undergone immunization prophylaxis and who had returned to complete their vaccination schedule [second dose of hepatitis A vaccine or third dose of hepatitis B/hepatitis A + B combined vaccine, or tetanus–diphtheria (Td) vaccine]. The CTMM practitioners had offered health advice following the World Health Organization guidelines for international travel.10 The survey included 28 questions on sex, age, countries visited, reason for travel, vaccination status, possible reactions/effects following vaccination, regimen of antimalaria prophylaxis (if carried out) and possibly related adverse effects, health problems experienced during travel, and behavior regarding food consumption (Appendix 1). The questionnaire was developed by the consultants of the CTMM, according to their experience. Subsequently, a pilot study was carried out among a small representative sample of the traveling population (50 subjects) to evaluate participation in the project, correct interpretation of the questions by all the responders, correspondence between the written answers given by the responders and their replies in a parallel interview held by the same practitioners. Results The study was carried out from January 1, 2003, to December 31, 2004. Of those scheduled to receive a further dose of vaccine by the end of 2004 (1,462 subjects), 1,237 travelers (84.6%) returned to the CTMM. The questionnaire was proposed to all of the latter, and 1,176 subjects (95.1%) agreed to participate in the study. The remaining travelers that returned did not fill in the questionnaire because they were not interested in the project or for lack of time during the vaccination session. It is worth stressing that the study population represents a self-selected group of travelers, particularly careful about health problems and with a high level of compliance. The survey was completed by 1,176 travelers: 573 males and 603 females. The length of time between the end of travel and the new visit to the CTMM, age distribution and the length of stay abroad are reported in Table 1. In particular, the journeys planned by the responders were, on average, rather long compared to other studies: 60% lasted longer than 2 weeks. The main reasons for travel were tourism (82.8%), followed by participation in international aid programs (8.7%), work (6.4%), and study (1.9%). J Travel Med 2006; 13: 338–344
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Table 1 Distribution of time-lapse between end of travel and new visit to Centre of Travel and Migration Medicine, age distribution of travelers, and travel duration declared by responders Time since the end of travel Months 12 Not available
Age of travelers
Duration of travel
N travelers (%)
Years
N travelers (%)
Days
N travelers (%)
60 (5.1) 46 (3.9) 40 (3.4) 47 (4.0) 78 (6.6) 166 (14.1) 269 (22.9) 158 (13.4) 81 (6.9) 57 (4.8) 45 (3.8) 25 (2.1) 44 (3.7) 20 (1.7) 40 (3.4)
60 Not available
35 (3.0) 364 (31.0) 429 (36.5) 158 (13.4) 119 (10.1) 68 (5.8) 3 (0.3)
1–7 8–14 15–21 22–30 >30 Not available
105 (8.9) 354 (30.1) 407 (34.6) 197 (16.8) 105 (8.9) 8 (0.7)
Travelers visited 97 countries: 39 states in Africa, 25 in Asia, 16 in North and Central America, 8 in South America, 6 in Europe and 3 in Oceania. The countries most visited were India and Tanzania (116 travelers each), Kenya (98), Mexico (93), South Africa (71), Peru (64), Brazil (54), Thailand (52), Egypt (49). A total of 234 travelers visited more than one country. With regard to immunization, 3,588 completed vaccinations were carried out by the staff of the CTMM. All participants were vaccinated with at least one dose of their vaccine. Almost all of those filling in the questionnaire were immunized against hepatitis A (96.9%), while 66.2% were vaccinated against hepatitis B, 56.3% against typhoid fever, 38.7% against Td, 37.2% against yellow fever, and 8.8% were vaccinated against meningitis. With regard to vaccination against hepatitis A and B, 752 travelers were vaccinated against both these with a combined vaccine (rarely with separate vaccinations, except in the case of last minute travel), 388 were vaccinated only against hepatitis A, and 26 only against hepatitis B. These data offer further evidence of the high compliance of the study population compared with the average population of travelers. Only 114 of those who filled in the questionnaire reported slight side effects following vaccination. Thirty travelers reported more than one symptom. The main symptoms were local pain at the site of inoculation (57.9%), tiredness (28.9%), and fever (14.9%). About 55% of the travelers (646/1,176) took chemoprophylactic measures against malaria since J Travel Med 2006; 13: 338–344
they were visiting high-risk countries: the medication most used by these 646 travelers was mefloquine (68.7%), followed by chloroquine (12.5%), chloroquine–proguanil (11.3%), and atovaquone– proguanil (6.7%). Generally, chemoprophylactic medication was taken following specific indications (88.4%), with a minimum of 73.6% for travelers visiting Southern Africa. A total of 72 travelers failed to follow indications mainly through deliberate choice (41.7%) or owing to side effects (34.7%). Other reported reasons of noncompliance were forgetfulness (13.9%) and absence of mosquitoes (2.8%). Chemoprophylactic measures against malaria were taken by 85.5% of travelers visiting sub-Saharan Africa, 42.0% visiting Asia, and 40.2% visiting South Africa. Figure 1 reports the use in percentage of each antimalarial drug per traveler that underwent chemoprophylaxis per visited area. Among travelers that underwent antimalarial chemoprophylaxis, 27.6% reported having one or more side effects (but only 14% interrupted treatment) (Table 2). Mefloquine caused side effects in 32% of the travelers that took this medication; however, also chloroquine–proguanil caused a considerable number of side effects (28.8%), while atovaquone–proguanil and chloroquine were responsible for side effects in 16.3% and 8.6% of travelers, respectively. The most frequent side effects were nausea (44.4%), stomachache (23.6%), feeling generally unwell (20.8%), insomnia (20.2%), tiredness (19.1%), restlessness (16.9%), vertigo (16.9%), diarrhea (15.7%), and nightmares (14.6%). These
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Travelers’ Compliance to Prophylaxis and Behavior Use of each antimalarial drug by visited area
Percentage (%)
100 80 60 40 20 0 Mefloquine Cloroquine Cloroquine+Proguanil Atovaquone+Proguanil Proguanil
Mediterranean Africa
Subsaharan Africa
Southern Africa
87.0 1.9 2.8 7.7 0.0
80.6 2.8 8.3 8.3 0.0
0.0 100.0 0.0 0.0 0.0
Asia
46.8 6.5 37.7 7.8 0.6
North-Central America
Southern America
Oceana
8.8 89.5 0.0 0.0 0.0
76.5 23.5 0.0 0.0 0.0
100.0 0.0 0.0 0.0 0.0
Figure 1 The percent use each antimalarial drug by travelers that adopted chemoprophylaxis measures by visited area.
data agree with the range of reactions to antimalarial drugs reported in other studies: the long time span between the end of travel and representation at the Table 2
clinic might explain the lower percentage of adverse effects reported by the travelers in our study.11–14 The remaining 530 travelers reported that they did not use chemoprophylactic measures for different reasons mainly because these were not required for the country visited (52.8%). For other subjects, prophylaxis was not used through deliberate choice (23.2%) because not recommended by friends (8.9%) or by the general practitioner (5.3%) or by the travel agency (3.0%). Some questions investigated the occurrence of health problems and other unforeseen events during travel in the countries visited. Questions concerned episodes of diarrhea, fever, and other diseases, the need for medical attendance or hospitalization. Out of all the travelers, 30.8% had episodes of diarrhea, 9.1% fever, 3.7% contracted other diseases (malaria, influenza, otitis, upper respiratory tract infection, erythema, etc), and a total of 6.5% of the travelers consulted a physician while abroad.
Total number of travelers with side effects related to malaria prophylaxis Drugs for malaria prophylaxis
Travelers that used antimalarial drugs Nausea Stomachache Slight illness Insomnia Tiredness Restlessness Dizziness Diarrhea Nightmares Drowsiness Headache Anxiety disorder Palpitations Abdominal pain Weakness Blurred vision Vomiting Hallucinations Depression Photosensitization Mental confusion Rash Liver pain Aerophagy Rise in transaminase levels Gastrointestinal disturbance Epistaxis Fever Gastritis
Mefloquine
Chloroquine–proguanil
Atovaquone–proguanil
Chloroquine
Proguanil
444
73
43
81
1
65 34 29 35 26 26 25 21 25 16 18 16 15 9 10 5 6 6 6 6 5 3 1 1 1
Total number of adverse effects related to malaria prophylaxis 9 2 3 5 1 2 5 2 1 5 2 3 1 2 2 1 2 3 2 1 2 1 1
3
1
2 1
1 1
1 1
1
1
1
1 1 1 1
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342 Concerning unpredictable events during travel, 1.5% of travelers reported accidents (road accidents, fractures, traumas, injuries), 3.8% erythema, and 4.4% significant reactions due to insect bites. In addition, 16.8% of travelers reported they had been either bitten or stung by insects such as mosquitoes, spiders, ticks, fleas, ants, horseflies, tsetse flies, wasps, leeches. Some reported infection due to foreign bodies lodged after poorly medicated (or nonmedicated) injury from a sea urchin and from monkey bites. The final questions concerned attention to avoiding potentially risky food and drink: 68.6% of travelers declared that they were careful about consuming food and drink. The remaining 31.4% reported being cautious at the beginning of travel (4.8%) or partially cautious (19.7%); 6.0% of travelers were not cautious about any food. However, 236 travelers had episodes of diarrhea despite their declared attention to food. Conclusions To the best of our knowledge, our descriptive study represents the first attempt in Italy to verify the behavior of travelers who consulted the center of travel medicine before their journey and for the second time on reentry after their journey. Questionnaire-based studies may assist workers in the field of travel health to understand the issues surrounding advice to the public and compliance with advice given. However, the limits of such an approach need to be underlined. This is in fact an exploratory study on an appropriate sample of patients addressing to a travel clinic. This sample is probably not representative of the overall Italian traveling population. There might be significant potential for selection bias (ie, volunteers), information bias (ie, recall), confounding, seasonal, and interannual variations. Other limitations of the study are that there may be bias by those that responded and those that did not: although participation in the study was very high, the few nonresponders may have not done so because they were noncompliant. Another important bias may be the time-lapse between travel and completion of the questionnaire (generally 5–7 months). The findings of this exploratory study may be further validated in future controlled deductive studies on health behavior, requiring incorporation of methods used in behavioral sciences. Given these points, the analysis of survey answers allows us to draw some hypotheses, both on the J Travel Med 2006; 13: 338–344
Laverone et al. work of the travel clinic in Florence (vaccinations and counseling) and concerning the behavior of travelers during their journeys. With regard to vaccination, an average of 3.1 doses were administered to each subject, offering a high degree of protection against all possible travelrelated vaccine-preventable diseases. Of particular concern is the fact that not all recommended vaccinations could be carried out due to limited time before departure (especially regarding last minute travel). Concerning chemoprophylactic measures against malaria, out of the travelers that were under treatment, 88.4% took their programmed medication accordingly and concluded their prophylaxis. Advice on malaria prevention was well publicized and strategically proposed to our target population. Our findings agree with previous studies that recommended mediating between effectiveness of protective action, improving travelers’ adherence, and increasing perception of efficacy.15,16 In addition, appropriate counseling was effective in inducing a substantial number of our sample of travelers to accept restrictions of consumption of “potentially dangerous” food and drink. Although food safety education programs are essential for reducing the incidence of travel diarrhea, many authors consider pretravel advice on diarrhea attacks unsatisfactory because behavior modification among tourists is considered very difficult.17–22 This would seem to be confirmed by the 236 cases of diarrhea in those travelers of our sample who also reported caution regarding the consumption of food and drink. Overall, this study reveals the high level of travelers’ observance of advice and, consequently, the efficacy of counseling by the CTMM. Nevertheless, this picture must be considered as a best case scenario (those who seek advice are likely to follow it through) if, as reported by Van Herck et al in the survey on international travelers departing from several European airports, only 73% asked for general information about their destination, and as little as 52.1% asked for advice on health safety related to their journey. The same study estimated that only 35.3% of travelers that asked for health advice was addressed to travel clinics, although this source is considered the most trustworthy by all travelers.4 Fundamentally, our study shows that centers of travel medicine can be very effective in protecting travelers’ health, provided that the large majority apply for advice before departure, which is clearly not the case at present. However, it is not possible to tell if the remainder of the traveling population
Travelers’ Compliance to Prophylaxis and Behavior seeks other sources of information, other providers or carries out self-medication. Much effort is needed to make these centers more widely known by the general population, especially through renewed collaboration with travel agencies and tour operators. An agreement by all involved parties is called for to uniform information on health risks during international travel. This should include a clear indication to visit a center of travel medicine well in advance of departure, especially when long-term travel and planned travel with long stays and close contacts with the local population are concerned.
Declaration of Interests The authors state that they have no conflicts of interest.
References 1. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travellers. J Travel Med 2004; 11:23–26. 2. Toovey S, Jamieson A, Holloway M. Travellers’ knowledge, attitudes and practices on the prevention of infectious diseases: results from a study at Johannesburg International Airport. J Travel Med 2004; 11:16–22. 3. Wilder-Smith A, Khairullah NS, Song JH, et al. Travel health knowledge, attitudes and practices among Australian travellers. J Travel Med 2004; 11:9–15. 4. Van Herck K, Van Damme P, Castelli F, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. J Travel Med 2004; 11:3–8. 5. Van Herck K, Kuckerman J, Castelli F, et al. Travellers’ knowledge, attitudes and practices on prevention of infectious diseases: results from a pilot study. J Travel Med 2003; 10:75–78. 6. Decree March 17, 1995, N. 111. Endorsement of Directive N. 90/314/CEE regarding travels, holidays and ‘all inclusive’ packages. Gazzetta Ufficiale della Repubblica Italiana April 14, 1995, n.88. 7. Total number of travellers crossing the borders by area. Ufficio Italiano dei Cambi. Available at: http:// www.uic.it/UICFEWebroot. (Accessed 7 February 2006)
343 8. Total number of passengers. Florence Airport. Available at: http://www.aeroporto.firenze.it/. (Accessed 7 February 2006) 9. Total number of international passengers. Pisa International Airport. Available at: http://www. pisa-airport.com/. (Accessed 7 February 2006) 10. International travel and health, World Health Organization, 2005. Available at: http://www.who.int/ith/en. (Accessed 2 February 2006) 11. Overbosch D, Schilthuis H, Bienzle U, et al. Atovaquone-proguanil versus mefloquine for malaria prophylaxis in nonimmune travelers: results from a randomized, double-blind study. Clin Infect Dis 2001; 33:1015–1021. 12. Hogh B, Clarke PD, Camus D, et al. Atovaquoneproguanil versus chloroquine-proguanil for malaria prophylaxis in non-immune travellers: a randomised, double-blind study. Lancet. 2000; 356:1888–1894. 13. Schlagenhauf P, Tschopp A, Johnson R, et al. Tolerability of malaria chemoprophylaxis in non-immune travellers to sub-Saharan Africa: multicentre, randomised, double blind, four arm study. BMJ 2003; 327:1078. 14. Petersen E, Ronne T, Ronn A, et al. Reported side effects to chloroquine, chloroquine plus proguanil, and mefloquine as chemoprophylaxis against malaria in Danish travelers. J Travel Med 2000; 7:79–84. 15. Lobel HO, Baker MA, Gras FA, et al. Use of malaria prevention measures by North American and European travellers to East Africa. J Travel Med 2001; 8:167–172. 16. Laver SM, Wetzels J, Behrens RH. Knowledge of malaria, risk perception, and compliance with prophylaxis and personal and environmental preventive measures in travellers existing Zimbabwe from Harare and Victoria Falls International Airport. J Travel Med 2001;8:298–303. 17. Mattila L, Siitonen A, Kyronseppa H, et al. Risk behavior for travelers’ diarrhea among finnish travelers. J Travel Med 1995; 2:77–84. 18. Rack J, Wichmann O, Kamara B, et al. Risk and spectrum of diseases in travelers to popular tourist destinations. J Travel Med 2005; 12:248–253. 19. Steffen R, Tornieporth N, Clemens SA, et al. Epidemiology of travelers’ diarrhea: details of a global survey. J Travel Med 2004; 11:231–237. 20. Al-Abri SS, Beeching NJ, Nye FJ. Traveller’s diarrhoea. Lancet Infect Dis 2005; 5:349–360. 21. Peetermans WE, Van Wijngaerden E. Implementation of pretravel advice: good for malaria, bad for diarrhoea. Acta Clin Belg 2001; 56:284–288. 22. Ericsson CD. Travellers’ diarrhoea. Int J Antimicrob Agents 2003; 21:116–124.
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Appendix 1. Questionnaire on prophylactic measures and behaviour during stay abroad 1. Date of birth: __ __/__ __/__ __ __ __ 2. Sex (male/female): []M []F 3. Country visited: ………… 4. Reason for travel: [ ] tourism [ ] business [ ] volunteer purpose [ ] study [ ] adoption [ ] other: ………… 5. Duration of travel (days): [ ] 1-7 [ ] 8-14 [ ] 15-21 [ ] 22-30 [ ] more than 30 days 6. vaccinations administered: [ ] yellow fever [ ] hepatitis A [ ] hepatitis B [ ] meningococcus [ ] tetanus-diphtheria [ ] typhoid fever [ ] rabies polio [ ] other: ………… 7. Did you have side effects after vaccination? [ ] No [ ] Yes 8. If Yes, which? [ ] temperature [ ] local pain [ ] rash [ ] tiredness [ ] other: ………… 9. Did you use antimalarial chemoprophylaxis? [ ] No [ ] Yes (if No, go to question no. 15) 10. If Yes, what drug did you use? [ ] chloroquine [ ] chloroquine/proguanil [ ] mefloqhine [ ] atovaquone/proguanil [ ] other: ………… 11. Did you use the drug according to prescription? [ ] No [ ] Yes (Chloroquine and mefloqhine: once a week, beginning a week before departure, throughout travel and for four weeks after returning. Proguanil: every day, beginning one day before departure, throughout travel and for four weeks after return. Atovaquone-Proguanil: one tablet per day, beginning one day before departure, throughout travel and for seven days after return) 12. Did you have side-effects after taking this drugs? [ ] No [ ] Yes 13. If Yes, what? [ ] nausea [ ] vomiting [ ] dizziness [ ] stomachache [ ] insomnia [ ] nightmares [ ] drowsiness [ ] abdominal pain [ ] restlessness [ ] depression [ ] indisposition [ ] anxiety disorder [ ] tiredness [ ] weakness [ ] blurred vision [ ] hallucinations
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14.
15.
16. 17.
18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
28.
[ ] headache [ ] diarrhoea [ ] palpitations [ ] mental confusion [ ] other: ………… If you interrupted antimalarial chemoprophylaxis, what was the reason? [ ] occurrence of side effect [ ] deliberate choice [ ] forgetfulness [ ] other:………… If you did not use antimalarial choemoprohylaxis, what was the reason? [ ] it was not required for the country visited [ ] previous side effects with recommended drugs [ ] deliberate choice [ ] it was not recommended by friends [ ] it was not recommended by the travel agency [ ] it was not recommended by my general practitioner [ ] other:………… Did you visit malaria endemic areas during travel? [ ] No [ ] Yes If Yes, did you use accessories and behave in order to avoid insect bites (clothes with long sleeves, insect repellent, mosquito net, insecticide, fumigator, propagator of insecticide)? [ ] No [ ] Yes During travel did you get diarrhoea? [ ] No [ ] Yes During travel did you get a temperature? [ ] No [ ] Yes During travel did you get any disease? [ ] No [ ] Yes If yes, which?………… During travel did you need to consult a doctor/ hospital? [ ] No [ ] Yes During travel did you have any accident (road accidents, fractures, wounds, traumas)? [ ] No [ ] Yes During travel did you have evident reactions to insect bites? [ ] No [ ] Yes During travel did you have trouble with the exposure to sunlight? [ ] No [ ] Yes During travel were you bitten by animals or insects? [ ] No [ ] Yes During travel did you pay attention to avoid potentially risky foods and drinks? [ ] Yes [ ] only at the beginning of travel [ ] partly [ ] No How long is it since you returned from travel (months): ………… Date of survey compilation: __ __/__ __/__ __
