SMJ 2003: 48(2) 49-51
Jonathan
H. Cossar*,1, Eleanor Wilson1,
Dermot H. Kennedy 2, Eric Walker1
1Scottish
Centre for Infection and Environmental Health, Glasgow, 2The Brownlee Centre,
Gartnavel General Hospital, Glasgow, UK.
Correspondence
to: Dr Jonathan H Cossar, Primary Care Consultant Advisor, SCIEH, Clifton House,
Clifton Place, Glasgow G3 7LN.
Email: jon.cossar@scieh.csa.scot.nhs.uk
The
authors have no financial or other conflicts of interest to disclose.
Abstract
A
comparative study was made of patients admitted over 12 months to the principal
infectious diseases unit for Glasgow in 1985 and in 1998/99.
During this interval UK travel statistics show a 135% growth in visits
abroad and a 5% rise to 17% in destinations with a risk of malaria.
Travel associated admissions rose by 96% to a total of 108.
Patients of Asian/Oriental ethnicity declined from 55% to 18%, whilst
Caucasians increased from 38% to 81%. Travellers
aged 20-39 years formed the modal age groups (51% and 50%).
Gastro-intestinal problems accounted for the largest single diagnostic
category in both study periods, 38% and 40% respectively.
In-patients diagnosed with malaria fell by 20%; these figures are cause
for encouragement to those involved in the teaching and dissemination of advice
on malaria prophylaxis. The
findings re-enforce the need for the continuation and expansion of travel health
education for both healthcare professionals and the public.
Keywords:
Travel related admissions, inpatient demographics, infectious diseases, malaria,
hospitalisation costs.
Introduction
In
1985 a study was made of inpatients with travel related illnesses admitted to
the Infectious Diseases (ID) wards at Ruchill Hospital, Glasgow1,2.
This facility was transferred to the new Infection, Tropical Medicine and
Counselling Service, at the Brownlee Centre, in the nearby Gartnavel General
Hospital in February 1998. During
this interval there has been a 135% growth in visits abroad from the UK with a
disproportionate growth to areas beyond Europe3,4 (Table
I).
Countries with a risk of malaria now include 17% of these destinations
(formerly 12%), visits to Africa have remained the same (1%), whilst the
proportion visiting the Americas has risen to 10%.
In view of this increase both proportionate and absolute in UK travellers
to countries with a higher risk of malaria and other unfamiliar pathogens a
review study was carried out during 1998/99.
This study data was collected as a subset derived from the ongoing
sentinel surveillance on travel related illness at infectious disease units
throughout Scotland.
M
Between 1st October 1998 and 30th September 1999 hospital referral data (both outpatient and inpatient) was collected twice weekly at the Brownlee Centre. The 1985 data1 was collected on a proforma completed at the time of patient discharge and then collated. The data from both study periods included age, gender, ethnicity, days hospitalised, days since return to the UK, countr(y/ies) visited, types of illness/diagnoses, and the total number of all inpatients in the Unit. Day cases were counted as outpatients. Although the hospital’s catchment area remained as before, children under 14 years were now excluded. Due to this latter change, children under 10 years old were removed from the 1985 data (retrieval of individual case records for 10-13 years olds from 1985 was not possible; this had minimal effect on data comparison). The monthly data were collated and compared.
UK
travel data for 1985 and 1999, derived from the Business Monitor Annual
Statistics3,4, provided further comparison, as did the malaria statistics from
the PHLS Malaria Reference Laboratory5(1985 and 1998).
Results
There was a 5% increase in all inpatients in 1998/99 compared to 1985 (Table II). This however included an absolute rise in travel associated admissions - from 55 to 108 (a 96% increase) - and a proportionate rise from 4% to 8%. The male: female ratio rose from 1.6:1 to 2.9:1, and there were major shifts in the different ethnic proportions. Patients of Asian extraction declined from 55% to 18%, whilst Caucasians increased from 38% to 81%, of travel related admissions.
The mean age of travel related admissions was similar at 36 years for 1985 and 38 years for 1998/99 (Table III). The 20-39 year age group accounted for most admissions (51% in 1985; 50% in 1998/99) although there was a preponderance of 20-29 year olds in 1985 (33%) and equal proportions of 20-29 and 30-39 year olds in the later study.
The median time from return home to referral dropped from 14 to 5 days (Table IV). The median inpatient stay reduced from 5 to 4 days and the bed day total rose by 25% in the 1998/99 study.
Pakistan was the most common origin of illness in 1985 (36% of the total) but accounted for only 6% of the 1998/99 admissions (Table V). Proportionate totals for in-patients who visited India dropped from 24% to 12%. These changes are also reflected in the proportion of those visiting Asia dropping from 62% to 23%. Other changes are a fall in those visiting Spain from 15% to 8%, and rises for Africa from 15% to 20% and the Americas from 2% to 7%. The total for countries visited in 1998/99 (133) exceeds the inpatient total (108) due to visits by some patients to more than one country.
In respect of clinical problems, the proportion of inpatients with a gastro-intestinal problem rose from 38% to 40%, the total with malaria was reduced from 20 to 16 (proportionately down from 36% to 15% of all travel admissions), whilst the total for all other diagnoses rose from 14 to 49 (a proportionate rise from 25% to 45%).
The
cost per bed day at the Brownlee Centre in 1998/99 was £4285.
This gives an annual total of £230,692 for all travel related admissions
(£428 ´
539 days), and an average cost for travel patients of £2136 (total annual cost ¸
108 inpatients). A comparable cost
in 1985 but employing a different costing methodology was £5351 per admission.
This figure was used in an extrapolation to calculate a theoretical
figure for total UK hospitalisation costs from travel related admissions in
1985. Taking the 1998/99 average
patient cost and using the same methodology to that employed in 19851, a
comparable calculation of the total for UK travel hospitalisation costs can be
made for 1998 viz. 11% of 17.44 million visits (= total unwell)
´
2% (= total hospitalised) ´
£2136 = total cost. This total is
£81.95 million compared with £15.3 million in 1985.
However, there are clear limitations in generalising these figures to the
whole UK, viz. they relate to inclusive tour holiday/”package” travellers
only, the study numbers are small, and no account is made for potential
demographic differences.
Discussion
Since the first study in 1985 the ensuing 13 years have seen increases in the number of UK visits abroad both to the most popular destinations and the total destinations visited. There have also been other changes in the nature and style of travel. This comparative study sought to explore the influence of these changes on travel related illnesses experienced by patients admitted to the principal Infectious Disease Unit for Greater Glasgow. Although the site of the Unit has moved about 2.5 miles south west from the original location, there has been no change in the catchment area served, nor has there been any change in referral policy such as day care or emergency out-patient review for these patients.
One of the most remarkable contrasts is in the increase in patients of Caucasian ethnicity when compared to others. In the absence of any significant change in the ethnic proportions within the catchment area, this may reflect the major increase in visits abroad to all areas or an increase in visits abroad to more hazardous destinations by Caucasians. Nevertheless this could also be accounted for by a reduction in numbers of, or better prevention of illness in, travellers from the other groups. Between 1985 and 1999 the population of Greater Glasgow has fallen by 6.6%7,8, but population breakdown by ethnicity for the hospital catchment area, for Greater Glasgow or for Scotland is not possible from available statistics. (Anecdotally, one of the authors (JHC) has been in primary care practice (30+ years), and lived in, the hospital catchment area (50+ years); he has not noted any significant demographic changes over the study timespan.)
In both study periods the modal age group is the 20-29 year olds. However by 1998/99 this rate is shared with the 30-39 year age group. Perhaps this reflects a continuing interest in adventure/higher risk travel in those younger travellers from the 1985 period.
The reduction in median time from return to admission may reflect several factors: the types of illnesses presenting are more acute, or there is an increased awareness about early referral by the traveller or his/her doctor. Although travel related admissions have increased and account for a major rise in bed occupancy in the later study, the bed occupancy increase is much less than would be expected from what is a virtual doubling of travel related admissions. This would support the view that inpatients with travel related illnesses are being both diagnosed and treated more expeditiously than before. Administrative pressures to increase the bed turnover rate may also have influenced this change.
It is of interest to look at the changes in the ID admissions alongside the changes in UK travel patterns over the same period of time. Comparison between the proportional rises in travel related admissions in Glasgow with total UK visits abroad (96% Vs 135%) is reassuring particularly in view of the greater increase in UK visits to areas beyond Europe (515%) between 1985 and 1998; but perhaps it merely reflects that Glaswegians are less adventurous in their travel destinations and/or more circumspect in their risk-taking behaviour. The majority of these more remote destinations carry a higher risk of pathogen exposure for this larger number of UK visitors when compared to travellers in 1985. Comparison of the travel destinations for residents in the hospital catchment area to that for UK travellers was not attempted.
The 8% drop of imported UK malaria cases between 1985 and 1998 is encouraging. At the same time there was a proportionate increase in cases of falciparum malaria from 30% to 68% of these totals, and cases of vivax declined from 61% to 24%. More deaths from malaria were recorded. These changes are compatible with less travel by immigrant families to the Indian subcontinent and increased travel to Africa. Despite the rise in cases of falciparum malaria recorded in the UK, inpatients diagnosed with malaria at the Brownlee Centre fell by 20% and the number with falciparum was unchanged.
The gastrointestinal illness total rose by 105%, confirming that food and water hygiene remains a major hazard. The remaining diagnoses are a mixed group which now account for 45% of the travel related admissions. Pyrexia was noted as a feature in 7%, respiratory problems in 12%, and STDs 5%. The apparent increase in this group of miscellaneous illnesses is a concern as these may be rarer and more difficult to prevent, recognise and treat.
In
conclusion, the overall changes in numbers, proportions, diagnoses, and
destinations seen in travel related admissions to the Brownlee Centre are
broadly in line with that expected from the growth in numbers of travellers and
the change in destination pattern of UK residents (Table
I).
The malaria figures are cause for encouragement to those involved in the
teaching and dissemination of advice on malaria prophylaxis. Although travel
associated admissions almost doubled, the reduction in mean stay time and the
lower proportionate rise in bed days occupied by these patients is perhaps
indicative of more expedient clinical management.
The other findings re-enforce the need for the continuation and expansion
of travel health education for both healthcare professionals and the public.
There is potential for considerable financial savings from effective
travel health education and from reduced travel related hospital admissions.
Acknowledgements
We
appreciate the help of all the medical and nursing staff at the Brownlee Centre
who assisted with the data collection. Our
thanks to Gwen Allardice, Statistician, SCIEH, for reviewing the presentation
and interpretation of the study figures.
REFERENCES
1
Cossar JH. Studies on illnesses associated with travel. (MD Thesis).
Glasgow: University of Glasgow,1987.
2
Cossar JH, Reid D, Fallon RJ et al.
A cumulative review of studies on travellers and their experience of
illness and the implications of these findings. J. Infect 1990; 21: 27-42.
3
Office for National Statistics. MQ 6: Overseas travel and tourism.
Table 8A. London: The Stationery Office,
1986:13.
4
Ibid. Tables 14; 18. 1999: 16, 20.
5
The Public Health Laboratory Service, Malaria Reference Laboratory.
Personal communication.
6
The Scottish Health Service Costs Book. Edinburgh: Information &
Statistics Division National Health Service
in Scotland, 1999: 92.
7
Registrar General for Scotland Annual Report 1985: p26. Edinburgh: HMSO.
8
Ibid. 1999: p20.