Eurosurveillance, Volume
9, Issue
3,
01 March 2004
Editorial
Gastrointestinal illnesses in tourists: whose responsibility?
R Cartwright1
Citation style for this article: Cartwright R. Gastrointestinal illnesses in tourists: whose responsibility?. Euro Surveill. 2004;9(3):pii=448. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=448
Date of submission:
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Professor Rodney Cartwright
Medical Advisor, United Kingdom Federation of Tour Operators
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Improvements in public health and the control of communicable
diseases throughout Europe have been achieved due to the multidisciplinary
approach and not only as a result of efforts of public health physicians.
The conclusions of the Spanish team (1) that studied the outbreak of gastroenteritis
in tourists visiting the Dominican Republic provides a good example of
the need for both cross discipline and international cooperation. Tourism
is one of the top three global economic forces, with an increasing number
of tourists each year. It is estimated that there are over 70 million
package holidays sold in Europe annually with destinations worldwide.
The tourists are exposed to a wide range of conditions and pathogenic
organisms.
There is, however, a paucity of information on the infections acquired
by these tourists during their travels. Surveillance is rudimentary, and
relies largely on reported illnesses in those who remain ill, or develop
an illness, on their return home. Apart from infections such as typhoid
fever, there is rarely any follow up, and the transfer of timely information
between the health ministries of different countries is variable. The
majority of travel acquired infections cause illness during the stay in
a destination country, are hardly ever recorded in any official surveillance
system, and are equally rarely investigated.
Yet questionnaire studies (2-5) on returning travellers, or in resorts,
indicate that there is a considerable incidence of gastric upsets in tourists
travelling to a number of destinations. This form of surveillance does
not provide information on the causative organisms, but does provide a
pointer for further investigation into the illnesses, the level of the
public health infrastructure, and the effectiveness of any food hygiene
programs. The information has been used by the major British tour operators
in discussion with the governments of holiday destination countries.
The failure of official surveillance systems to detect these illnesses
is due in part to confusion about who is responsible for dealing with
tourists' gastrointestinal upsets. Most of those who are ill in a resort
leave for home in a matter of days, and in other cases the illness may
only become apparent after the tourists have returned home.
The importance of these illnesses, some of which are mild and of short
duration, should not be underestimated. They cause discomfort to those
directly affected but will also have an impact on the holiday enjoyment
of others in their party. There may in addition be severe economic consequences
for the resort community, especially if tourism is adversely affected
by bad media coverage in the tourists' home countries.
The tourist industry will usually become aware of a problem at an early
stage as tourists complain to the local representatives. This information
needs to be shared with health officials in both the home and the holiday
countries. National surveillance systems need to be aware of travel connections
and while maintaining patient confidentiality, need to alert other countries
and the tourist industry of potential trouble areas. The speed of travel
and the numbers of travellers make it very important for even unsubstantiated
data to be shared at an early date. There may be no laboratory diagnosis
but as we all know, John Snow was able to take action before the cholera
vibrio was recognised.
The prompt transfer of data between health departments of different countries
and the tourist industry, which can directly and immediately influence
hoteliers, would be an important step in reducing the burden of gastrointestinal
illness in tourists. The development of working arrangements between national
health departments, tour operators and hoteliers should be encouraged
before an incident occurs, with an emphasis on the implementation of effective
preventative programs.
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References
1. A Páez Jiménez, R Pimentel, MV Martínez de
Aragón, G Hernández Pezzi, S Mateo Ontañon, JF
Martínez Navarro. Waterborne outbreak among Spanish tourists
in a holiday resort in the Dominican Republic, August 2002. Eurosurveillance
2004; 9 (http://www.eurosurveillance.org/em/v09n03/0903-222.asp)
2.Cartwright RY. Food and waterborne infections associated with package
holidays. J Appl Microbiol 2003;94 Suppl:12S-24S.
3. Steffen R, Collard F, Tornieporth N, Campbell-Forrester S, Ashley
D, Thompson S, et al. Epidemiology, etiology, and impact of traveler's
diarrhea in Jamaica. JAMA 1999;281:811-7.
4. Steffen R, van der Linde F, Gyr K, Schar M. Epidemiology of diarrhea
in travelers. JAMA 1983;249(9):1176-80.
5. Reid D, Dewar R, Fallon RJ, Cossar JH, Grist NR. Infection and travel:
the experience of package tourists and other travellers. J Infect. 1980;2:365-70.
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