Scandinavian Journal of Primary Health Care

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Health Problems in Norwegians Travelling to

Distant Countries

Linn Getz, Karl-Erik Larssen, Bente Dahl & Steinar Westin

To cite this article: Linn Getz, Karl-Erik Larssen, Bente Dahl & Steinar Westin (1990) Health
Problems in Norwegians Travelling to Distant Countries, Scandinavian Journal of Primary Health
Care, 8:2, 95-100, DOI: 10.3109/02813439008994938

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 Scand J Prim Health Care 1990; 8: 95-1 00

Health Problems in Norwegians Travelling to Distant Countries

LINN GETZ', KARL-ERIK LARSSEN', BENTE DAHL3, STEINAR WESTIN4

',.'Department of Communiry Medicine and General Practice, Universiv of Trondheim, N-7030 Trondheim, Norway,
2t3TrondheimHealth Board, Prinsens gate 61, N-7011, Trondheim, Norway

Getz L, Larssen K-E, Dahl B, Westin S. Health problems in Norwegians travelling to distant
countries. Scand J Prim Health Care 1990; 8: 95-100.
373 travellers to countries outside Europe and North America were recruited before departure
summer 1988 at the Vaccination OftTce, 'Ikondheim, Norway, and participated in a follow-up
study on health problems related to travel. 313 of the travellers (84%) responded by answering
a postal questionnaire one month after return; it dealt with prophylactic measures, life-style,
and health problems associated with travelling. An 18% failure in malaria prophylaxis and
some risk-taking behaviour related to alcohol and sex were recorded. Diarrhoea (usually mild)
was reported by 59%; other symptoms were also frequent. Medical advice was sought by 18%
while abroad; 7% consulted a doctor. Ill health made travelling less enjoyable than expected
for 8%. After return, 25% had health problem; 9% saw a doctor, three travellers were
hospitalized, and 6% were absent from work. Total morbidity was high, but seldom serious.
Targeted advice, which can well be given by primary health care personnel, could help to
reduce morbidity and risk behaviour and improve travellers' handling of ill health.
Key words: travel medicine, international travel, infectious diseases, third world, survey,
health problems, Norwegians.
Linn Getz, MD, Department of Community Medicine and General Practice, University of
'kondheim, N-7030 Tkondheim, Norway.

Record growth of international travel has resulted in
300 million people crossing international frontiers
every year, including an annual 16 million journeys
from industrialized to developing countries (1).
Several studies indicate that many travellers expe-
rience health problems as a direct result of their
travel. The percentage reporting ill health vanes
according to travel destination and study criteria;
15% is the lowest figure reported, but it is much
higher if smaller problems are included (2-5). Such
surveys have their limitations; it is difficult to obtain
accurate epidemiological information concerning
travellers' health. Recommendations for disease
prophylaxis during travel should be based on in-
formation about potential health risks, but feedback
from travellers themselves is also essential.
Several studies show lack of uniformity in advice
and varying knowledge about the subject of trav-
ellers' health amongst health professionals dealing
with pre-travel consultations - and also problems
related to compliance, particularly concerning ma-
laria prophylaxix (6-8). There are not many other
Scandinatian studies on travellers' health (9-1 1).
In order to improve the quality of pre-travel
health advice, we conducted a study on the health of
travellers from Trondheim, Norway.
SUBJECTS A N D METHODS
The Vaccination Office of Trondheim Health Board
serves the city of Trondheim and adjoining commu-
nities; travellers come there directly or after referral.
All travellers who consulted the Vaccination Office
between 24 May and 24 October 1988, prior to a
journey outside Europe or North America, were
invited to particiate in a follow-up study on their
health during and after travel. They received a pre-
travel questionnaire to fill in while waiting for immu-
nizations. The questionnaire had two purposes; first
to encourage the travellers to participate in the fol-
low-up study, and secondly to obtain information
about their knowledge of some important health

Scand J Prim Health Care 1990; 8

96 L. Getz et al.
BEFORE TAAVEL questionnaire which enquired about knowledge of
WRING TRAVEL
100 health risks. Results are reported elsewhere (14).
4! 319 (85%) returned the post-travel questionnaire
80 following their trip. Six had not been outside Eu-
rope, probably due to change of plans, and were
60
excluded from further study. One person was killed
40 in a mountaineering accident whilst abroad; further
information on the non-respondents was not avail-
20 able. Table I gives details of the travellers and travels
0 of the 313 respondents (84%) included in the fol-
HEALTHY MINOR PROelEMS MAJOR PROBLEMS low-up analysis - 171 men and 142 women, mean age
Fig. 1. Travellers' evaluation of their physical and mental 37.1 years.
health before and during travel (N=313).
Preventive measures and life-style while abroad
risks (e.g. malaria, HIV, diarrhoea). Travellers were Eight travellers had no insurance cover for illness
given immunizations, immunoglobulin, and a pre- whilst abroad. 86 travellers carried no kind of first
scription for malaria prophylaxis according to in- aid equipment. 17 travellers had bathed in fresh
ternational recommendations (12,13) - as well as water in countries where schistosomiasis is wide-
some general health advice concerning climate, pre- spread. Nine travellers, eight men and one woman,
vention of malaria, diarrhoea, HIV, etc. Travellers reported having had new sexual contact(s) whilst
received the main questionnaire (six pages, pre-paid
envelope enclosed, anonymous reply) one month Tab. I. Characteristics of travellers responding to
after their scheduled return - this interval covers the post-travel questionnaire (N=313) and their travels.
incubation period for most relevant diseases. A re-
minder was sent out two weeks later. The question- Number of
Characteristic travellers %
naire dealt with personal data, the nature of the
travel, malaria prophylaxis, any precautions taken,
Sex: Male 171 55
and life-style while abroad (consumption of food, Female 142 45
alcohol, sexual behaviour, accidents). It further
Mean age: 37.1 years (SD 12.9)
asked about gastro-intestinal and other symptoms,
the need for medical advice, and the consequences Age group: 10-29 years 115 37
3049 138 44
of illness (e.g. change of plans, absence from work).
50-79 58 19
Travellers rated their subjective well-being (physical Unknown 2 <1
and mental) before and during the journey accord- Higher education qualifications 60
ing to a simple three-point scale shown in Figure 1. Health professionals 7
Health problems after return were also recorded. Travellers by occupation (sailors, etc.) 1
Statistical evaluation was done using the Pre-existing illness receiving treatment 5
Pregnant women 4 -
SPSS/PC+ statistical programme. Chi square tests
and Student's t-test were used to compare rates and Travel duration: 3.7 weeks (SD 2.8)
means. Cut-off points for age were as recorded in Destination(*): Oriental Asia 48
Table I. Sub-Saharan Africa 19
Middle EastNorth Africa 16
Latin America 16
RESULTS AustralidOceania 3

Participants and travels Visited major cities only 28

More than one week in rural areas 28
373 travellers were recruited. Those not included
Purpose: Vacation 67
were four children ( < l o yrs), six persons who did WorWStudies 26
not understand the questionnaire due to language Visit family/frienddAdoption 7
problems, and approximately 25 travellers not re- Travelling with tour guide 23
turning in time for the follow-up (1 February 1989).
All 373 participants completed the pre-travel (*) Five travellers had been to two continents.

Scand J Prim Health Care 1990: 8


Tab. 11. Use of prophylactic antimalarial drugs
(N=313).
Adequate Failure
Prophylaxis not required 35%
Prophylaxis indicated, not taken 6Yo
Prophylaxis taken (total 59%)
- with regularity or more or 47%
less regularly
- discontinued during travel 2 Yo
- discontinued at time of return
or within four weeks thereafter 10%
Prophylaxis according to 82% 18%
recommendations
abroad. Three (men) had always used a condom, the
rest had not.
Table I1 shows the use of prophylactic antimalarial
tablets by the travellers. At least 18% of the total
group failed to use them effectively.
Alcohol consumption was estimated by the fre-
quency with which travellers subjectively felt intox-
icated. 61% reported that they had not taken that
much alcohol at any time during the trip. The rest
had done so with varying frequency; 14% more than
twice a week. Reports of intoxication whilst abroad
were significantly more common in men than women
(p<O.OOl) and in age groups under 50 years
(p<O.OOl). Three male travellers reported problems
related to alcohol (being robbed, contracting veneral
disease, drinking polluted water).
Subjecrive grading of well-being
Figure 1 shows that 35% rated themselves lower o n
the subjective physical health scale whilst abroad,
while only 5% reported a corresponding downward
move in mental well-being. There was no difference
between men and women, but young people gener-
ally experienced more problems than older travellers
(p<O. 05).
In 35 persons (1 1 YOof travellers) health problems
had been sufficient to cause cancellation of plans.
Within this group the mean number of days “lost”
due to illness was 3.5 (SD 3.6). 25 travellers (8%)
stated that health problems had made the travel less
enjoyable than expected.
Travellers’ diarrhoea
Travellers’ diarrhoea (Table 111) - defined in the
questionnaire as loose and frequent stools - was
reported by 184 persons (59%). Most cases were
7 Primary Health Care
Health Problems in Norwegians Travelling 97
mild, but 13% had more severe attacks. There was
no significant difference between the sexes, but the
mean age of those affected by diarrhoea (35.5 years,
SD 12.6) was significantly less (p<O.Ol) than that of
those unaffected (39.4 years, SD 12.9). Other gas-
tro-intestinal symptoms showed the same pattern.
21% reported more abdominal pain than at home,
and 14% experienced more nausea and vomiting.
These symptoms were again more frequent
(p<O.OOl) in the youngest age group (<30 yrs).
There were significantly fewer diarrhoea1 episodes
in travellers who visited only first class restaurants
such as international hotels, compared with trav-
ellers who ate in smaller establishments or bought
food from street vendors (p<0.05). However, age
groups 30 years and older reported eating only in
first class restaurants significantly more often than
did the younger travellers (pt0.001). Stratified by
type of eating place (first class versus simpler estab-
lishments), data showed that age did not affect fre-
quency of diarrhoea in first class eaters (N=104).
Among those eating in simpler restaurants (N=207),
the youngest age group (<30 yrs) developed diar-
rhoea significantly more often than the older
(p<O.Ol).
It was not possible to demonstrate a significant
relationship between choosing only food that was
considered to be “safe” and the risk of diarrhoea;
travellers who did not take any particular dietary
precautions (1170)were not affected more fre-
quently than the 22% who stated that they had been
very careful o r the 66% who had taken a few precau-
tions.
Tab. 111. Frequency of travellers’ diarrhoea
(N=313).
Number of
travellers %
Short attack(s) or not confining 144 46
traveller to bed
Longlasting attack(s) or 25 8
confining person to bed
Diarrhoea with fever 15 5
Total frequency of diarrhoea 184 59
No diarrhoea 129 11
Total 313 100
Scand J Prim Heolth Cure 1990; 8
98 L. Getz et al.
Other symptoms and principal complaints
Symptoms other than those associated with gas-
troenteritis were also more frequent than at home:
exhaustion (28%), sunburn (21%), common colds/
pharyngitis (14%), insomnia (12%), fever (9%),
skin problems (9%), headache (7%), and dyspnoea
(5%; usually related to high altitude). Exhaustion
and suffering from the heat were significantly more
frequent in younger than in older age groups
(p<O.OOl), and the same was true for insomnia
(p<O.O5) and sunburn (p<O.OOl). These differences
are most likely due to differences in life-style. There
were also several reports of constipation and minor
accidents .
Travellers who suffered several problems were
asked to point out their principal complaint: in the
majority of cases it was gastrointestinal symptoms,
followed by upper respiratory infections, problems
related to climate, constipation, insomnia, and head-
ache. One young traveller reported feeling miser-
able because his girl-friend left him, and visitors to
the Summer Olympics complained about the heavy
pollution in the city of Seoul.
Medical help-seeking while abroad
56 travellers (18%) sought help once or more be-
cause of some health problem (66 consultations). 22
persons (7%) attended a doctor, 40 (13%) had been
to a pharmacy - and there had also been a few
consultations with other health staff. Only 13% of
the travellers seeking medical assistance reported
difficulties in obtaining help (language problems,
inappropriate advice, adverse reactions to medicines
recommended, and high cost). Help was sought
mainly on account of diarrhoea (52% of consulta-
tions), followed by skin problems ( ISYO) and upper
respiratory tract infections (14%). 19% of consulta-
tions were due to other problems.
Health problems after return
During the first month after returning home, 77
(25%) travellers experienced some kind of health
problem which they related to the journey. 28 (9%)
consulted a doctor. Three were hospitalized; diag-
noses were salmonellosis, yersiniosis, and deep ve-
nous thrombosis (“economy class syndrome” (15)
acquired during the return flight). 20 persons (6%)
had been absent from work or study for a mean of 4
days (SD 5.1).
The list of health problems was once again dom-
Scand J Prim Health Care 1990: 8
inated by gastro-intestinal problems - 39 cases (50%
of the reported post-travel problems), followed by
upper respiratory tract infectinos - 19 cases (25%),
and 14 cases (18%) of poor general health. Six (8%)
reported skin problems (infections, etc.), and there
were three cases of urinary tract infection. One vis-
itor to Eastern Asia (in autumn) returned with se-
vere, unusual headache which lasted for four weeks;
his doctor suggested it might be viral encephalitis.
21 (7%) of the travellers still had some health
problem which they related to the journey by the
time they answered the questionnaire one month
following their return.
DISCUSSION
The population included in this study may represent
a selected group, being recruited in a university town
and seeking pre-travel immunization and advice.
Little can be said about the health of travellers set-
ting out without seeking advice - which may well
occur due to the lack of vaccination requirements at
most frontiers. The response rate was high (85%),
but we do not know the characteristics of the re-
maining 15% who did not return the post-travel
questionnaire.
The validity of the results is influenced by the
subjective way in which health problems are re-
ported. The individual responses indicated varia-
tions in the threshold of reporting symptoms as ac-
tual problems. This problem was addressed by using
travellers as their own controls, asking them to com-
pare their health while abroad with their usual
health status. However, the study does not give truly
objective data concerning symptom frequency, but
should be a good indicator of travellers’ health expe-
rience.
One of the larger studies on travellers’ health,
involving over 10OOO Swiss travellers to developing
countries, reported the overall frequency of health
problems as 15% (2). Other studies, probably in-
cluding a wider range of complaints, or reflecting
high morbidity at particular destinations at partic-
ular times, report 30 to 70% affected (2-5). The
Swiss study (2) reported that 8% of travellers con-
sulted a doctor while abroad; our finding of 7%
indidcates that our data are representative for Eu-
ropean travellers in relation to the frequency of rela-
tively important health problems.
We lack precise information on the aetiology of
reported health complaints, but other studies pro-

vide information on the most frequent complaint
among travellers; diarrhoea (1). A total of 59% re-
porting one or more episodes of frequent and loose
stools (a wide definition), with a subgroup of 13% of
travellers suffering severe attacks, is higher than has
been reported in similar studies. The Swiss study (2)
reported severe diarrhoea in 8.5% of travellers to
developing countries. The significant association be-
tween younger age and travellers’ diarrhoea has
been found in other studies - authors discuss
whether this is due to difference in immunity o r
life-style. O u r results suggest that life-style does con-
tribute to that difference.
It is interesting to note that careful choice of food
did not significantly reduce diarrhoea frequency. In
another retrospective study (16), diarrhoea seemed
to be more frequent the more travellers tried to
prevent it by choosing “safe” foods. A later prospec-
tive study on the validity of the rule “Boil it, cook it,
peel it, or forget it” (17) did report a positive corre-
lation between the number of “dietary mistakes”
and the frequency of diarrhoea. The advice of a
doctor may help the traveller to understand “the art
of defensive eating”, but learning it probably also
takes experience and intuition.
The high frequency of travellers’ diarrhoea raises
the question of drug prophylaxis and treatment. An-
tibiotics, although effective according to several
studies, can hardly be recommended for prophylac-
tic use due t o the risk of side-effects. There are many
advocates of treatment by conservative measures on-
ly, in all but the most severe cases. Others accept
rather liberal use of antiperistaltics o r antibiotics
(both seem to reduce symptom duration) once diar-
rhoea is present (1). Our study indicates that trav-
ellers do seek advice about diarrhoea. Knowing that
strong antiperistaltics and antibiotics are of high
commercial value and are sold over the counter all
over the Third World, a “diarrhoea strategy” should
be discussed in the pre-travel consultation if we wish
to influence travellers’ ways of dealing with this
problem.
The 18% failure in compliance with recommended
malaria prophylaxis in our selected group merits at-
tention. The pre-travel questionnaire also revealed
that travellers had little knowledge about the disease
(14). Other studies have pointed to this problem,
indicating that even many health professionals lack
essential knowledge on the subject (6-8). The plu-
rality of drug regimens being used throughout the
world also adds to travellers’ confusion and lack of
7’
Health Problems in Norwegians Travelling 99
confidence in the usefulness of prophylaxis. For in-
stance, 16 different drug regimens were identified
among foreign residents in D a r es Salaam in 1983
(18). Our questionnaire asked about sources of in-
formation concerning travellers’ health, and this
seems to be a popularly discussed topic. The pre-
travel consultation must give constructive, precise,
and logical information if it is to compete with opin-
ions encountered in the traveller’s surroundings.
CONCLUSIONS A N D RECOMMENDATIONS
Morbidity amongst short-stay travellers to develop-
ing countries is not insignificant, but it is usually not
very serious or of a particularly “tropical” nature. To
a certain degree it is preventable. Travellers to en-
demic zones need to b e informed carefully about
malaria and its prophylaxis. Strategies related to
travellers’ diarhoea are better discussed before set-
ting out than in a Third World pharmacy. The cam-
paign for “safe sex” needs t o be continued. These
aspects of “travel medicine” can well be handled by
primary health care personnel. The travel industry
could also d o more to provide their customers with
appropriate health information.
ACKNOWLEDGEMENTS
We want to thank Professor Kjell Hellum in Trond-
heim and Dr. Jonathan Cossar in Glasgow for their
valuable advice, and Daniel Fosstvedt for computing
assistance. Dr. Karl-Erik Larssen died unexpectedly
while this article was in preparation. His enthusiasm
and personal support is gratefully acknowledged.
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Received November 1989
Accepted January 1990