• New report on foreign travel-associated illness –
  a focus on those visiting friends and relatives
  
• Confirmed measles cases in England and Wales –
  an update to end-November 2008
  

 

New report on foreign travel-associated illness – a focus on those visiting friends and relatives

A new travel health report, released by the Agency on 9 January, focuses on infectious diseases acquired by those travelling abroad to their country of origin (or that of their family) to visit friends or relatives (VFR)[1]. The report summarises trends in the latest available data related to VFR travel from the Office for National Statistics International Passenger Survey, together with the latest surveillance data available for malaria, enteric fever, and hepatitis A, three important infections associated with VFR travel.

People travel abroad for many reasons and the reason why they travel affects where they go, and therefore their risk of acquiring an infectious disease. In recent years, the number of visits abroad made by United Kingdom residents to visit friends and relatives (VFR) has increased by 67%, compared to 35% for holiday travel and 13% for business travel. VFR travel is now the second most common reason for travelling abroad in the UK and often involves travel to regions that have a higher risk of certain diseases such as malaria, enteric fever (typhoid and paratyphoid), and hepatitis A. A disproportionate number of people who have acquired malaria and enteric fever through foreign travel are those who have undertaken VFR travel (87% for enteric fever and 78% for malaria), though slightly different population groups are affected in each case.

Malaria predominantly affects those who were either born in Africa or are of African ethnicity who have undertaken VFR travel to West Africa, while enteric fever predominantly affects those who were either born in the Indian subcontinent (mainly India, Pakistan, and Bangladesh) or are of Indian subcontinent ethnicity who have undertaken VFR travel to the Indian subcontinent. While there is less information about hepatitis A, studies have shown that for travel-associated cases, travelling to the Indian subcontinent to visit friends and relatives is a significant risk factor.

Contributing factors for the disproportionate burden of typhoid, paratyphoid, and malaria in those travelling for VFR reasons were not seeking travel advice before their trip, and not using adequate prevention measures. VFR cases of enteric fever were less likely to have sought health advice before travel than non-VFR cases, particularly those who were non-UK born. The vast majority of malaria cases associated with VFR travel had not taken any chemoprophylaxis recommended by the HPA Advisory Committee for Malaria Prevention in UK Travellers [2].

Travel-associated illnesses do not generally pose a significant risk of onward transmission to the indigenous UK population. They can be very serious for those travellers affected, however, and to reduce the overall number of such illnesses reported in the UK, particular attention needs to be given to protecting the health of VFR travellers. Travellers visiting friends and relatives in countries with endemic infectious diseases need to be made aware of possible risks to their health. They should ideally seek travel health advice from their GP or a travel clinic at least six weeks before their trip, although it is never too late to seek advice before departure.

The report is available to download from the Agency website [1]. Hard copies will be available in February 2009 from tmhs@hpa.org.uk.

Advice on all aspects of pre-travel health is available from the National Travel Health Network and Centre at http://www.nathnac.org/.

The most up to date surveillance data for travel-associated diseases is available on the Travel Health page of the HPA website.

References

1. Health Protection Agency. Foreign travel-associated illness - a focus on those visiting friends and relatives: 2008 report. London: Health Protection Agency; December 2008. Available at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1231419801008?p=1158945066450

2. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, Bannister B. Guidelines for malaria prevention in travellers from the United Kingdom. London: Health Protection Agency; 2007. Available online at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733823080?p=1191942128258.

Confirmed measles cases in England and Wales – an update to end-November 2008

In November 2008, 115 cases of measles were confirmed in England and Wales (see figure 1), an increase on each of the previous two months (83 and 72 respectively). This increase was attributable to cases outside of London: the number of cases in London was the lowest monthly total this year [1].

A provisional total of 1,217 laboratory confirmed measles cases have been reported in 2008 up to the end of November, exceeding the total of 990 reported for the whole of 2007. The proportion of measles notifications confirmed by a positive oral fluid test was 21% in London and 27% in the rest of England and Wales.

Figure 1: Number of laboratory confirmed cases in England and Wales by month of onset: January 2007 to November 2008

The majority of the November cases (74%) were concentrated in the North West, South East and West Midlands regions (see table). These regions continued to identify cases linked with outbreaks in nurseries, and in primary and secondary schools. In West Midlands and South East regions cases were also linked to outbreaks in traveller communities. In addition, a nosocomial outbreak was identified when a healthcare worker became infected after attending a child with measles.

Confirmed cases of measles by region and month of onset, England and Wales: January 2008 to November 2008

Month	Lond-on	East Mids	East of Engl'd	North East	North West	South East	South West	West Mids	Wales	York. & Humber
Jan	60	1	8	1	1	1	-	3	1	11
Feb	44	-	4	3	-	7	-	-	-	3
Mar	67	1	1	-	-	6	1	1	1	5
Apr	94	-	8	3	1	6	15	2	-	15
May	103	1	6	-	23	4	7	3	-	4
Jun	100	-	10	1	22	7	3	5	-	3
Jul	68	1	10	-	22	17	3	8	-	2
Aug	31	8	8	-	14	17	-	6	-	2
Sep	29	3	3	-	7	2	-	9	20	-
Oct	44	13	5	2	35	10	1	10	14	1
Nov	12	7	10	2	27	24	1	30	1	1
Total	652	35	73	12	152	101	31	77	37	47

 

Figure 2: Confirmed cases by age groups targeted by the MMR catch-up programme, England and Wales: January 2008 to November 2008*

* Includes one case with unknown age.

Sixty-five percent of cases reported to November 2008 have been children less than 15 years of age: 1 to 4 years (301 cases), 5 to 9 (274 cases) and 10 to 14 (222 cases). Local MMR catch-up campaigns targeting children and youngsters up to the age of 18 years are ongoing in many areas [2, 3].

Both strains of the D4 genotype (MVs/Enfield/14.07 and MVs/Chester/38.08) are continuing to circulate in different parts of England and Wales.

An article published in The Lancet this week suggests that, due to suboptimum vaccination coverage in some countries, there is a real possibility that the European region may fail to meet the measles elimination goal set by the World Health Organization (WHO) [4]. The paper examines epidemiological data submitted by 32 countries in Europe to EUVAC.NET (a European surveillance network for vaccine preventable diseases) for 2006 and 2007. Over 12 thousand measles cases were reported, most of which (85%) were in Romania, Germany, Switzerland, Italy and UK.

References

1. HPA. Confirmed measles cases in England and Wales - an update to the end of October 2008. Health Protection Report [serial online] 2008, 2 (48); news. Available at: http://www.hpa.org.uk/hpr/archives/2008/news4808.htm#measles.

2.HPA. MMR catch-up programme announced. Health Protection Report [serial online] 2008, 2 (32); news. Available at: http://www.hpa.org.uk/hpr/archives/2008/news3208.htm#mmr.

3. Mass measles vaccination starts, BBC news England, 3 December 2008, http://news.bbc.co.uk/1/hi/england/manchester/7762174.stm.

4. Muscat M, Bang H, Wohlfahrt J, et al. Measles in Europe : an epidemiological assessment, The Lancet , published online 7 January 2009, DO1:10.1016/S0140-6736(08)61849-8. Available at: http://press.thelancet.com/measlesfinal.pdf.