Protecting Canadian travellers: Prevention is better than cure

As the winter travel season is upon us, it is worth knowing that an estimated 2 million Canadians will travel this year to developing countries; more than 20% of these travellers will be immigrants returning to their countries of origin to visit friends and relatives. Globally, international travel has increased dramatically. According to the World Tourism Organization (www.world-tourism.org), the number of travellers crossing international borders has grown from 457 million in 1990 to 842 million in 2006. In addition, travellers are visiting more exotic destinations, and “voluntourism” is gaining momentum as people volunteer in developing countries' orphanages, hospitals and construction sites to assist locals and gain insight.

Epidemiological studies have shown that up to 75% of travellers develop a travel-related illness.1 Recent reports from the GeoSentinel Surveillance Network for emerging infectious diseases have shown that gastrointestinal infections, dengue fever, malaria and typhoid fever are important causes of morbidity among returned travellers. About 50% of imported malaria cases and 80% of typhoid fever cases occur among immigrants who have visited their countries of origin, mostly West Africa and the Indian subcontinent.

Despite the growing number of travel clinics in Canada, rates of illness and death from vaccine-and drug-preventable diseases have increased or remained unchanged. Between 1996 and 2004, the number of typhoid cases almost doubled and the number of malaria cases has been static, with nearly 400 cases occurring between 1998 and 2004. Less than 15% of international travellers actually visit a travel clinic before departure and, unfortunately, the information that primary care practitioners give to their patients is often incorrect.

Sadly, travellers with the highest risk of illness — immigrants visiting their countries of origin and students — are the least likely to seek pre-travel health advice. Why is this? In a word, cost. Neither group can afford the substantial costs of the consultation fee, vaccines and antimalarial medications. For example, a family of 4 travelling to a yellow fever zone in West Africa for 1 month would need to spend at least $1900 on vaccines alone. In addition, immigrants visiting their countries of origin often mistakenly believe that they are immune to many infections endemic in those countries because of prior exposure. It is common for adult immigrants visiting their countries of origin to bring their Canadian-born children to travel medicine clinics for pre-travel health advice and vaccinations but to accept only those vaccines required to cross international borders (e.g., vaccines against yellow fever or meningococcal meningitis) for themselves.

Unfortunately, there are no data on the cost of travel-related illness to the Canadian health care system. However, the cost is likely to be substantial, as demonstrated by a study in the United Kingdom that indicated imported tropical infections cost infectious disease units about £800 000 per year.2 One researcher estimated that the cost of treating imported cases of malaria in the United Kingdom was greater than the cost of providing travellers with antimalarial prophylaxis.3

Why don't provincial health care plans cover travel medicine? This was a deliberate decision made by government bureaucrats in conjunction with provincial medical associations, rather than by health care policy experts. The underlying rationale seemed to be that “if one can afford to travel, one can afford to pay.” This may be true of the vacationer or business traveller, but not of the immigrant visiting his or her country of origin, the student, or the altruistic volunteer. Immigrants visiting their countries of origin usually travel out of necessity to visit ill relatives, attend marriages and funerals or bring their Canadian-born children to visit family.

Given the substantial burden of travel-related illnesses to Canadians and our health care system, governments should do more. If provincial health plans covered at least the cost of the pre-travel consultations, this would encourage travellers to seek health advice from knowledgeable providers, who could use this opportunity not only to provide specific travel-related advice and vaccinations, but also to update routine vaccinations. The costs of pre-travel consultations and of inexpensive vaccines and malaria prophylaxis would likely be easily offset by the savings owing to reduced health care costs from imported infectious diseases. As occurs with drugs and other medical technologies, policy-makers should base decisions about travel medicine funding on independent economic evaluations from expert bodies rather than on the misconception that travel medicine is a luxury item. Political will is needed to ensure that, just as in other contexts, effective preventive care is provided to those who need it most.