Population‐Based Survey of Travel Patterns Among Canadians Visiting Hepatitis A–Endemic Countries: Table 1

Each year, approximately 42 million trips are made outside Canada, and this number is constantly rising.1,2 The increasing number of trips is largely attributable to visits of tropical and subtropical areas, where hygiene and health care standards may be different than those existing in North America. While hepatitis A (HA) is the most common vaccine‐preventable disease among travelers,3,4 it can also be considered an interesting marker of the hygienic infrastructure of the destination countries and for the general risk of enteric diseases. An analysis of the patterns of travel in HA‐endemic countries may therefore be useful to assess the general health risks of travelers. Most published studies in the medical literature have focused on the travel patterns of individuals visiting travel clinics. Because only a very small percentage of travelers seek appropriate pretravel health services,5 these studies are subject to selection bias in that they mostly reflect the travel patterns of risk‐conscious individuals. Planning prevention programs requires reliable data on travel patterns of all individuals, in particular those unlikely to visit travel clinics. The objective of this population‐based study was to describe the travel patterns of Canadians who went to HA‐endemic countries between 1990 and 1999. A phone survey was conducted between October 27 and December 6, 1999, among adults selected through random‐digit dialing and residing in either Quebec (7 million people) or Ontario (12 million people), the two largest provinces of Canada, documenting travels to HA‐endemic countries between 1990 and 1999. Details on study design have been previously published.5,6 For the current analyses, comparisons of proportions were made using results from the chi‐square test or Fisher’s exact test. The Mantel–Haenszel chi‐square test for trend was used for polytomic ordinal variables, whereas the two‐sided Cochrane–Armitage exact test for trend was used with dichotomic variables. Among the 4,002 respondents, 1,070 (27%) had traveled at least once to an HA‐endemic country between January 1990 and November 1999. These participants completed a total of 2,444 trips; for 1,934 (80%) trips (three most recent ones), we obtained detailed information. Respondents born in HA‐endemic countries traveled more frequently than those born in Canada (54% vs 24%, p < 0.001). The annual proportion of adults who traveled increased from 3% in 1990 to 6% in 1999 (chi‐square trend p < 0.001). However, while in 1990 only a small difference existed between the proportion of travelers among respondents born in Canada (2.7%), those born in HA‐nonendemic countries (2.0%), and those born in endemic countries (2.7%), this difference was larger at the end of the decade (5.2%, 8.6%, and 13.5%, respectively). The median number of trips per traveler was 2.0. The median duration of travel was 14 days: 41.7% of the trips lasted 1 to 7 days, 26% were 8 to 14 days, 15% were 15 to 21 days, and 14% lasted more than 3 weeks. Tourism was the most frequent reason for travel (86% of all trips), while business accounted for 11.5% and volunteer work for 2.4%. In decreasing order of frequency, travelers visited Latin America and the Caribbean (76%), Asia (11%), Eastern Europe (8%), and Africa (5%). The four most visited countries were Mexico (24%), Dominican Republic (10%), Cuba (8%), and Jamaica (5%). Trips made to Latin America and the Caribbean were of shorter duration than to other regions. One‐week trips represented 56% of those to the four most frequently visited countries, while those of more than 2 weeks accounted for only 15%. The proportion of travelers who were aware of health hazards associated with their destination was higher in those who visited Africa (76%) and Asia (74%) than in those who traveled to Latin America and the Caribbean (55%) and Eastern Europe (47%) (p < 0.05). The proportion of trips with all nights spent in a first‐class hotel was greater in Latin America and the Caribbean (49%) than for other destinations (17%–20%). High‐risk travel (trips that lasted more than 4 weeks during which more than half of nights were spent in low‐budget accommodations) accounted for only 2% of all trips made to HA‐endemic countries, whereas low‐ to moderate‐risk travel represented 36% and 40% of the trips respectively (Table 1). Surprisingly, one quarter of all trips classified as high risk were made for business purposes, while only 5% were undertaken by volunteers. Characteristics of trips according to risk level, purpose of trip, and country of birth Data in bold show a statistically significant difference between categories. HA = hepatitis A; VFR = visiting friends and relatives. Characteristics of trips according to risk level, purpose of trip, and country of birth Data in bold show a statistically significant difference between categories. HA = hepatitis A; VFR = visiting friends and relatives. One in five trips (22%) was to visit friends and relatives (trips where more than half of nights were spent in the homes of friends or relatives) and was more often undertaken by respondents born in an HA‐endemic country. High‐risk travelers whose destinations were well distributed between the different continents were also more aware of travel‐related health risks than other travelers (88% vs 55%, p < 0.001). High‐risk trips were significantly more often undertaken by younger travelers (<24 years of age), individuals with postsecondary education (>16 years), and those with a slightly higher annual household income. Nearly half of the business trips (119/203) were in Latin America and the Caribbean but they accounted for only 9% of trips to that continent, whereas they represented 16% to 21% for other regions. Business trips lasted longer than those for tourism and were more frequently undertaken by people aged 35 to 44 years with higher education and income levels. The proportion of trips where all nights were spent in a first‐class hotel was similar during business and tourism trips (39% vs 42%, respectively). The proportion of trips where ≥50% meals were eaten in low‐budget facilities was similar during tourism and business trips (6% vs 7%) but higher during volunteer work trips (13%). Awareness of health risks was generally higher for business trips (66.1%) than for tourism (56.3%) but lower than for volunteer work (74.5%). Canadian‐born travelers were more likely to visit Latin America and the Caribbean than were foreign‐born travelers. Nearly one third of travelers born in HA‐endemic countries had overseas stays exceeding 1 month compared to less than 10% for all other travelers. Tourism was the main purpose of travels for all individuals, but respondents born in HA‐nonendemic countries were more likely to travel for business purposes (19%) than respondents born in Canada (11%) or endemic countries (8%). Respondents born in HA‐endemic countries stayed more often with friends and relatives while traveling (71% vs 11%–19%), more often self‐organized their trips (81% vs 36%–49%), and stayed abroad for longer periods than did travelers born in Canada or in another HA‐nonendemic country. Respondents born in HA‐endemic countries generally had a lower annual household income than Canadian‐born travelers. Population‐based studies of travel patterns are rare in the medical literature,7 and to our knowledge, this is the first study of this kind involving Canadians. Because Ontario and Quebec represent 62% of the entire Canadian population, and given the sample methods used, we are confident that our data are likely to be representative of the travel habits of most Canadians. Our results may also be applicable to a wider set of travelers since studies have shown that US travelers have habits similar to those of Canadians. Between 1990 and 1999, about one quarter of Canadians visited a country where HA is endemic. This means, for any general practitioner, that every fourth patient seen may travel in an HA‐endemic area and should be counseled about the risks and hazards of traveling in these areas of the world. Our results show that between 1990 and 1999, the proportion of adults who traveled to a country where HA is endemic almost tripled and that, during the same period, about one quarter of Canadian adults surveyed undertook one or more such trips. Despite historical events such as SARS (2003), 9/11, and subsequent tensions in the Middle East, reports from Statistics Canada show that travel patterns to HA‐endemic countries have not significantly been affected except on the short‐term and that the proportion of travelers is still on the rise. Surprisingly, only 5% of the high‐risk trips were for volunteer work, while one quarter of trips for business purposes fell into this category. While business travelers have a different risk profile than other travelers,8,9 they may nevertheless engage in similar activities when the workday is over.10–12 The general belief that business travelers use first‐class facilities while volunteers stay in low‐budget hotels may need to be revised, our results emphasizing the need to devote more attention to these travelers. Our results also show that Canadians born in HA‐endemic countries are more likely to visit an HA‐endemic area than their counterparts, have an extended stay, and stay with friends and relatives. While traveling, they may have a false sense of security regarding health risks compared to other travelers, or they may find themselves in social situations in which adherence to medical recommendations regarding food and water precautions is difficult.13 We should note, however, that travel in foreign‐born households may have been underestimated as we excluded those where no adult spoke English or French (which represented ∼10% of all households). With the rapid increase in immigration from the developing world in recent years and the decrease in transportation costs, it is sensible to anticipate an increase in travel‐related diseases among this group of travelers. Promotional approaches designed to reach the young backpacker are unlikely to be successful when used to target the business traveler or first‐ or second‐generation immigrants visiting friends and relatives. Interventions must be designed and adjusted to fit the distinct travel patterns of each of these groups. Because pretravel advice is typically sought by less than 20% of travelers,5 it is long overdue that public health authorities develop a variety of realistic strategies to reach the 80% of travelers who do not visit a travel clinic prior to departure and take into consideration their specific needs. We are grateful to Kevin Kain, Gina Pohani, Monique Douville‐Fradet, Louis Rochette, and Nicole Boulianne for their contribution to the initial study6 which was the basis for the current article. This study was funded by an unrestricted grant from GSK Canada. GDS and BD served as unpaid members of vaccine advisory committee, GSK Canada. Otherwise, the authors have no conflict of interests to declare.

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