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Travel-associated sexually transmitted infections: an observational cross-sectional study of the GeoSentinel surveillance database

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Summary

Background

Travel is thought to be a risk factor for the acquisition of sexually transmitted infections (STIs), but no multicentre analyses have been done. We aimed to describe the range of diseases and the demographic and geographical factors associated with the acquisition of travel-related STIs through analysis of the data gathered by GeoSentinel travel medicine clinics worldwide.

Methods

We gathered data from ill travellers visiting GeoSentinel clinics worldwide between June 1, 1996, and Nov 30, 2010, and analysed them to identify STIs in three clinical settings: after travel, during travel, or immigration travel. We calculated proportionate morbidity for each of the three traveller groups and did logistic regression to assess the association between STIs and demographic, geographical, and travel variables.

Findings

Our final analysis was of 112 180 ill travellers—64 335 patients seen after travel, 38 287 patients seen during travel, and 9558 immigrant patients. 974 patients (0·9%) had diagnoses of STIs, and 1001 STIs were diagnosed. The proportionate STI morbidities were 6·6, 10·2, and 16·8 per 1000 travellers in the three groups, respectively. STIs varied substantially according to the traveller category. The most common STI diagnoses were non-gonococcal or unspecified urethritis (30·2%) and acute HIV infection (27·6%) in patients seen after travel; non-gonococcal or unspecified urethritis (21·1%), epididymitis (15·2%), and cervicitis (12·3%) in patients seen during travel; and syphilis in immigrant travellers (67·8%). In ill travellers seen after travel, significant associations were noted between diagnosis of STIs and male sex, travelling to visit friends or relatives, travel duration of less than 1 month, and not having pretravel health consultations.

Interpretation

The range of STIs varies substantially according to traveller category. STI preventive strategies should be particularly targeted at men and travellers visiting friends or relatives. Our data suggest target groups for pretravel interventions and should assist in post-travel screening and decision making.

Funding

US Centers for Disease Control and Prevention, and International Society of Travel Medicine.

Introduction

Travel is thought to be a risk factor for the acquisition of sexually transmitted infections (STIs) because it disrupts individuals' usual sexual practices through physical separation of partners and removal of social taboos that might inhibit sexual freedom.1, 2, 3 Published reports about travel-associated STIs focus wholly on risk behaviour and small single-clinic analyses, but no multicentre analyses of the clinical range of travel-related STIs have been done. Most reports show that travel increases exposure to STIs, which can be attributed to the high rate of casual sex and low rate of condom use.1 A systematic review4 published in 2010 showed a pooled prevalence of travel-associated casual sex of 20·4% (95% CI 14·8–26·7%), and almost 50% of these sexual encounters were unprotected.

Hypothetically, the risk of acquisition of STIs in travellers is a product of the number of sexual partners, use of condoms, and the prevalence of STIs in other travellers and the contact population of the destination country. Prevalence in the destination country is affected by the uneven distribution of STIs worldwide. The estimated incidence of new cases of bacterial and protozoan STIs in 1995 was 330 million worldwide; 150 million cases were in southeast Asia and 69 million in sub-Saharan Africa, compared with 14 million in North America (ie, Canada, Mexico, Puerto Rico, and the USA) and 16 million in Europe.5 In an earlier proposed model for the interpretation of phase-specific epidemiology of STIs based on the dynamic interplay between pathogens, human behaviours, and control efforts,6 low-income countries almost invariably were in the hyperendemic phase, implying high incidence and prevalence of STIs in the general population.

Worldwide, international tourist arrivals have increased from 150 million in 1970 to almost 1 billion in 2011 (with an increase of 4% in 2011),7 potentially enhancing the interaction between travel and the spread of STIs. Examples of the public health effects of such interactions include prognosis, diagnosis, and treatment of HIV infection in developed countries affected by the importation of several viral clades,8 syphilis outbreaks in northern Europe introduced from Russia,9 and quinolone-resistant Neisseria gonorrhoeae strains spread to the USA and Europe from southeast Asia, prompting changes in treatment recommendations for gonorrhoea.10

Despite these findings, evidence is scarce for the effect of travel on the acquisition of STIs. Prospective data for incidence in travellers are unavailable, and details about the extent of travel-related STI morbidity are sparse. The range of STIs occurring in travellers is poorly documented, with just one report about a small sample of travellers from a single clinical setting in France.11

GeoSentinel, a global sentinel surveillance network established in 1995 through a collaborative effort from the International Society for Travel Medicine and the US Centers for Disease Control and Prevention,12 provides a means to assess the epidemiology of travel-associated illness in travellers and immigrants. We used the GeoSentinel database to describe the range of STIs in ill travellers visiting GeoSentinel sites and to describe geographical and demographic factors in GeoSentinel patients with STIs.

Section snippets

Study sites

GeoSentinel sites are specialised travel or tropical medicine clinics with global distribution at which point-of-care, clinician-based sentinel surveillance data are gathered. They are staffed by clinicians who are recruited on the basis of their knowledge and experience in travel and tropical medicine.12 The GeoSentinel network is the largest available database of ill travellers. To be included, patients had to have crossed an international border within 10 years before the clinic visit and

Results

We included data gathered between June 1, 1996, and Nov 30, 2010. 112 180 ill travellers met our inclusion criteria (figure 1). 974 of these people (0·9%) had an STI, and 1001 STIs were diagnosed. The probable country of exposure could not be established for all travellers. Table 1 shows the demographic characteristics of travellers with STIs, stratified by traveller group. A trip duration of less than 1 month was reported by 70% of travellers seen after travel and by 44% of those seen during

Discussion

Our study is the first large, multicentre analysis of the clinical range of travel-related STIs (panel). Despite the many studies about the risk-taking behaviours of travellers, information about the range and risk factors for STIs in travellers is scarce. Most published reports11, 14 are small case series from single centres. Strengths of our study include the large number of STIs analysed, the global multicentre perspective with standardised data, and the demographic and geographical

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