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Available at www.sciencedirect.com

Travel Medicine and Infectious Disease (2008) 6, 187–189

1477-8939/$ - see frodoi:10.1016/j.tmaid

$Presented as athe Journal of Travel2007, London, UK�Corresponding au

X01, Southdale 2135fax: +27 11 374 6507.

E-mail addresseDanuta.kielkowski@nafdefrey@wtmconlin(G. Brink).

journal homepage: www.elsevierhealth.com/journals/tmid

Travelling for work: Seeking advice in South Africa$

Mary H. Rossa,b,c,�, Danuta Kielkowskib,d, Albie de Freyb,c, Garth Brinkc

aDe Beers Global Mining, Private Bag X01, Southdale 2135, South AfricabUniversity of the Witwatersrand, Johannesburg, South AfricacSouth African Society of Travel Medicine, Johannesburg, South AfricadNational Institute for Occupational Health, National Health Laboratory Service, Johannesburg, South Africa

Received 3 January 2008; accepted 21 January 2008Available online 3 March 2008

KEYWORDSExpatriate;Infectious diseaseprevention;‘Last minute’ consul-tation;Occupational travel-ler;Sub-Saharan Africa

nt matter & 2008.2008.01.007

poster at the 2ndMedicine and Infe

thor at: De Beer, South Africa. Te

s: Mary.ross@debioh.nhls.ac.za (D.e.com (A. de Frey

SummarySub-Saharan Africa is a common destination for occupational travellers from South Africa.Adequate preventive measures require timeous medical consultation before travel. Asecondary analysis of datasets of over 8000 occupational travellers who visited travelclinics in South Africa indicated that 82% were travelling to African countries and over 50%consulted less than a week before travel. For the 70% who consult less than 10 days beforedeparture, yellow fever certificates issued at consultation would not be valid for entry toendemic countries, although they may be protected from contracting yellow fever. The‘last minute’ travel medicine consultation appears to be more common in South Africathan in Europe and North America. This may preclude South African health professionalsfrom providing occupational travellers adequate disease prevention, particularly againstvaccine-preventable infectious diseases.& 2008 Elsevier Ltd. All rights reserved.

Introduction

Sub-Saharan Africa is a high-risk destination for travellersand an important occupational destination for South African

Elsevier Ltd. All rights reserved.

International Conference ofctious Disease, 12 September

s Global Mining, Private Bagl.: +27 11 374 6935;

eersgroup.com (M.H. Ross),Kielkowski),), gkb@brink.za.net

workers.1 Potential occupational exposure to preventableinfectious diseases such as malaria, yellow fever andhepatitis necessitates timeous, risk-related preparation ofbusiness and expatriate travellers. This is particularlyimportant for those moving to high-risk areas remote fromaccess to health care.

The phenomenon of ‘last minute’ consultation is proble-matic for travel medicine practitioners and travellers and iswell-documented. It is reported that in travellers fromNorthern and Western Europe needing hepatitis A vaccina-tion to travel to developing countries, ‘for various reasons asignificant proportion may not present for vaccination untilthe last minute’.2 The authors suggest that some last minuteconsultation may reflect ‘a need to travel urgently and/orunexpectedly’ or a lack of awareness of the vaccine

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Table 1 Period between consultation and departure forall working travellers.

Period todeparture (days)

No. oftravellers

Percentage oftravellers

0–7 4366 54.58–14 1824 22.515–30 1161 14.5430 670 8.5

Total 8021 100

Table 2 Distribution of working travellers by continentdestination.

Continent No. oftravellers

Percentage oftravellers

Africa 5910 82.65Central and SouthAmerica

608 8.5

Asia 582 8.14Europe 24 0.34North America 16 0.22Australasia 11 0.15

Total 7151 100

0

5

10

15

20

25

30

35

Per

cent

age

Regions in Africa

North AfricaCentral AfricaWest AfricaEast AfricaSouthern AfricaIslands

Figure 1 Distribution of working travellers to Africa.

M.H. Ross et al.188

manufacturers’ recommendations. Quoting data presentedat the 3rd European Conference on Travel Medicine byConnor and Steffen, they report that the average time ofconsultation to departure was 31 and 23 days in Belgium andthe USA, respectively, while 7.8% of travellers in Europe and29% in the USA consulted a travel clinic a week or less priorto departure.2 Irish experience is similar to that in Belgium;based on over 20,000 travellers, 7% of leisure travellers and20% of business travellers consult in the week prior todeparture (G. Fry, data on ExodusTM, personal communica-tion).

South African occupational and travel medicine practi-tioners are concerned about expatriates whose ‘last-minute’ consultation pattern may preclude adequatedisease prevention and preparation for travel.3 In anoperational record review of 3584 business and vacationtravellers consulting a Johannesburg based travel clinic, itwas found that in ‘last minute’ travellers who consult aweek before departure, a significant difference existedbetween leisure travellers (20%) and business travellers(49%) who consulted less than a week before departure.3

Following these findings, the South African Society of TravelMedicine (SASTM) established a national sentinel surveil-lance group based in main centres in South Africa toinvestigate pre-travel consultation patterns for SouthAfrican travellers. The objective of the secondary dataanalysis of pre-travel consultation timing by occupationaltravellers was to compare them with leisure and religioustravellers and to provide information to travel medicine andoccupational medicine practitioners providing services toSouth African workers.

Materials and methods

A secondary data analysis was conducted on datasets of19,108 travellers who attended 24 sentinel general andtravel medicine practices in main South African centres fromJanuary 2005 to December 2006. Reason for travel,destination and time between consultation and departurewere submitted to the National Institute for OccupationalHealth in datasets, stripped of any personal identifiers.Datasets were cleaned, collated and one combined datasetwas analysed using the STATA 8 statistical software program.

Results

Occupational travellers or workers comprised 42% (8021) ofall travellers (19,108) consulting the 24 participating clinics,54% of workers consulted less than a week, 70% consultedless than 10 days, and 92% consulted less than a monthbefore travel (Table 1).

The mean ‘consultation to departure’ period was 15.2days (95% CI 14.5–16.01) which is 2.6 days less than theperiod for leisure travellers, and 22 days less than for peopletravelling for religious gatherings.

Countries in Africa are the destination for 82% (5910) ofthe working travellers who consult a travel clinic and forwhom a destination was recorded (7151); followed byCentral and South America (8.5%), Asia (8.1%) and the restof the world (shown in Table 2). Within Africa, the mostcommon destinations were countries in East Africa (34.5%),

Southern Africa including a small number within South Africa(34%), and West Africa (25%) (Figure 1).

For the 25% (1756) of workers who were travelling tocountries in West and Central Africa, which are consideredto be at higher risk for yellow fever than other Africancountries, 65% consulted less than 10 days before departure,although the mean period between consultation anddeparture was 13.2 days.

Discussion

Workers comprise a significant proportion of the clientelefor travel clinics in South Africa. The majority of theseworkers are travelling to Africa where there are destination

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Travelling for work: Seeking advice in South Africa 189

risks and often suboptimal health care facilities. It appearsthat the majority consult on average nearly 3 days nearer todeparture than do leisure travellers and over half ofoccupational travellers consult less than a week beforedeparture. This consultation pattern is considerably differ-ent to that of travellers in Ireland, where 20% of businesstravellers consult in the week before departure (G. Fry,personal communication). A major reason for consultingtravel clinics before travel to other parts of Africa is toobtain a yellow fever vaccination, which is required forentry into countries designated as having a risk of yellowfever exposure as well as for return into South Africa fromsuch countries. Since 65% of those travelling to higher risk(yellow fever) destinations consult less than 10 days beforedeparture, if this were for a yellow fever immunisation, theimmunisation certificates would not comply with the timespecification in the International Health Regulations.

A significant number of occupational travellers work inremote areas where there is an actual risk of contractingyellow fever. With the increase in exploration and miningactivities in remote areas in Africa, this risk is likely toincrease.

There is no opportunity to administer multidose vaccina-tion schedules which may compromise development ofimmunity against, for example, hepatitis B and rabies.

The profile of travellers attending the participating clinicsis thought to be relatively representative of South Africanworker and leisure travellers who consult health careproviders before travel. The datasets revealed limitationsin the consistency of what and how data were collected(e.g. 13% records did not include destination), which led toexclusion of some records from analyses and the proceduresor treatment given were not provided in the datasets.Limitations for the interpretation of the analysis are thatthere were no data provided on new versus repeat visits northe reason for consultation and what vaccines, prophylaxisand advice were offered to travellers. Travellers may havebeen consulting solely for malaria prophylaxis in which casethe shorter period before departure for repeat travellersmay have been sufficient. Most travel health specialists6

advise that malaria prophylaxis should be trialed for aperiod of 2–4 weeks prior to departure when used for thefirst time. Due to cost considerations, mefloquine is still verycommonly prescribed for South African travellers and aprophylactic course should ideally be commenced at least aweek prior to entering a malaria area. A large percentage ofoccupational travellers may be receiving their prophylaxisless than 7 days prior to departure.

However, malaria remains a major risk for occupationaltravellers from South Africa, particularly those sent forprolonged periods to remote areas,4,5 and adequatepreparation includes commencing prophylaxis well beforedeparture to preclude adverse reactions occurring insituations where there is little medical support or alter-native medications available.

Infectious diseases are not the only occupational risks towhich occupational travellers are exposed. In addition,particularly the expatriates often require prolonged pre-paration, including full medical and psychological evalua-tion, stabilisation of chronic diseases and culture training,to prevent other physical and mental health problems duringdeployment.

The data support the anecdotal impressions held by SouthAfrican occupational health practitioners that employees donot consult in time for adequate preparation before travel.The South African Society for Occupational Medicine willcollaborate with SASTM to explore ways of increasing theperiod between consultation and departure and raisingawareness of the particular needs of occupational travel-lers. In future, SASTM will provide a uniform data collectionprotocol to its sentinel surveillance clinics to encourage theinclusion of what procedures and treatment were providedplus history of previous and consultation vaccinations andprevention. This should provide better information ondeficiencies and indicate needs for education of travellers.To facilitate prospective data collection, a client consentform has been designed for obtaining permission to usecollective anonymous data.

Conflict of interest

No financial support was received for the dataset analysis.The third and fourth authors contributed datasets from theirpractices and were involved in the previous pilot review forthe South African Society for Travel Medicine. The authorshave no conflicts of interest to declare.

Acknowledgements

These data were presented as a poster at the 2ndInternational Conference of the Journal of Travel Medicineand Infectious Disease, 12 September 2007, London, UK. Theauthors acknowledge the contributions of anonymousdatasets to the South African Society for Travel Medicineby the following travel medicine practitioners: Sr. J. Ensor,Dr. N. Bhatta, Sr. M. Haasbroek, Dr. B. Bull, Dr. A.Q.A. Surve,Dr. A. Adams, SAHVC Travel (Medicity) Clinic, Dr. B.Kloppers, Dr. H. Snyman, Dr. P. Vincent, Sr. E. Trenholm,Dr. D. Hyams, Menlynmed Travel Clinic; and the assistancewith analysis from epidemiologists, Mr. B. Bello and Ms. K.Wilson, at the National Institute for Occupational Health,South Africa.

References

1. Leggat PA, Frean J. Health countermeasures for militarydeployment. Occup Health Southern Africa 2006;12:4–11.

2. Connor BA, Van Herck K, Van Damme P. Rapid protection andvaccination against hepatitis A for travellers. Biodrugs2003;17(Suppl. 1):19–21.

3. Brink G, De Frey A, Ensor J, Ross M, Kielkowski D. Pre-travelconsultation patterns in South African travel clinics. In: Postersession: 10th conference of the international society for travelmedicine, 2–5 May 2007. Vancouver, Canada.

4. Hodge M, Ross MH. Malaria surveillance within a travel healthservice in the mining industry. Occup Health Southern Africa2006;12:32–4.

5. Ross MH, de Frey AF, Frean J. Seasonal malaria in SouthernAfrica. In: Schlagenhauf-Lawlor, editor. Travelers’ malaria.Hamilton: BC Decker Inc.; 2008.

6. Steffen R, Dupont HL, Wilder-Smith A, editors. Manual of travelmedicine and health. 2nd ed. Hamilton: BC Decker Inc.; 2003.