Section 6-9: Canadian Guidelines on Sexually Transmitted Infections – Specific populations – Travellers

Section 6 - Specific Populations

Travellers

Definition

There has been a long-standing association between travel, sexual behavior and the risk of acquiring sexually transmitted infections (STIs). Travellers are defined as people who are journeying temporarily, permanently or episodically for recreational or occupational reasons.Footnote 1 Categories of travellers include but are not limited to: tourists, business travellers, military personnel, seamen, truckers, diplomats, college and university students on school break and immigrants visiting their country of origin.Footnote 2-Footnote 4 Sex tourists are a particular category of travellers whose main intention is to engage in sexual activity when abroad.Footnote 2 They are more likely to engage in sex with sex workers and to have multiple partners when travelling.Footnote 2 Prostitution has developed around tourist resorts in some countries, particularly in Southeast Asia and increasingly in Eastern Europe.Footnote 2,Footnote 5,Footnote 6

Epidemiology

In 2002, Canadians took 13 million overnight trips to the United States with an average length of stay of 4 nights and 4.7 million trips overseas with an average length of stay of 15.2 nights.Footnote 7 The ten most popular destinations in descending order (excluding the USA) were the United Kingdom, Mexico, France, Cuba, the Dominican Republic, Germany, Italy, the Netherlands, Spain and China.Footnote 7

The risk of acquiring STIs is increased in travellers because travel affords freedom from the normal social constraints of daily life at home as well as increased time and opportunity for casual sex.Footnote 8 Studies have shown that 5-50% of travellers engage in casual sexFootnote 1,Footnote 9,Footnote 10 and that 1/3 to over 1/2 of travellers do not consistently use condoms.Footnote 1,Footnote 11 Those at higher risk include males, younger travellers, those who are travelling alone or with friends, those who are single, men who have sex with men (MSM), those planning a long duration of stay, those travelling on business, smokers or those using alcohol or illicit drugs.Footnote 1,Footnote 4,Footnote 5,Footnote 8,Footnote 11,Footnote 12

STIs are among the most common notifiable infections worldwide, with rates being particularly high in developing countries.Footnote 1 Chlamydia trachomatis is the most prevalent bacterial STI worldwide.Footnote 11 Gonococcal infections remain common worldwide, with the incidence of antibiotic resistance increasing. Antimicrobial susceptibility patterns of Neisseria gonorrhoeae vary worldwide, with a high prevalence of resistance seen in Africa and Asia.Footnote 9,Footnote 11 For further information on antimicrobial resistance, see Gonococcal Infections chapter.

The World Health Organization estimated that, worldwide, at the end of 2003, there were 38 million adults and children living with HIV – 4.8 million infected in 2003 alone.Footnote 13 In Canada, the HIV epidemic is largely due to infection with B subtype viruses. However, travellers may be at risk for transporting non-B subtypes of HIV virus home.Footnote 2,Footnote 6

Prevention and Control

Evidence of the effectiveness of pre-travel interventions is very limited.Footnote 1,Footnote 8,Footnote 14 Health care workers should advise travellers to take condoms with them, alert them to the high rates of STIs and reinforce the message that alcohol or illicit drug use lowers inhibitions.Footnote 5,Footnote 10,Footnote 11,Footnote 14 Travellers should be informed that condoms available overseas may be of inferior quality and that hot, humid conditions can decrease effectiveness of condoms.Footnote 11 Collaboration between travel clinics and STI programs or clinics is helpful in ensuring appropriate prevention and treatment.Footnote 1

Hepatitis B virus (HBV) vaccine is recommended for travellers to areas of HBV endemnicity.Footnote 10,Footnote 15,Footnote 16 Up-to-date information on HBV prevalence can be found on the World Health Organization website on International Travel and Health at International travel and health - 2012 Edition or by consulting the 2001 International Travel Health Guide.Footnote 17 Hepatitis A virus (HAV) vaccination is recommended for MSM, injection drug users and travellers to countries where HAV is endemic to prevent person-to-person transmission of HAV.Footnote 15,Footnote 16 Combination vaccines for HAV and HBV are useful for patients who require protection against both infections. Chemoprophylatic use of antibiotics for the prevention of STIs while travelling is not recommended.Footnote 5

Prevention efforts should also be targeted at immigrants from HIV-endemic countries who are at increased risk of acquiring HIV infection during visits to their country of origin following immigration to Canada.Footnote 3,Footnote 6

Evaluation

Early diagnosis and treatment is key in preventing further spread of STIs, particularly to regular sexual partners at home. A travel and sexual history should be taken. It is important to be aware that self-identified sexual identity is not an accurate predictor of sexual behaviour while travelling. Although some travellers may consider themselves heterosexual, they may have been involved in sexual activities with members of the same sex (either prior to and/or during travel). Therefore it is essential that a sexual history include questions regarding opposite sex and same sex activity. This can be achieved by asking open-ended questions such as: “Do you have sex with men, women or both?”

For a more complete discussion, see Men Who Have Sex with Men/Women Who Have Sex with Women and Primary Care and Sexually Transmitted Infections chapters.

Practices while travelling (both sexual and non-sexual) that are associated with an increased risk for acquiring STIs should be assessed. These include the following:

  • Unprotected oral, vaginal or anal intercourse (receptive and insertive).
  • Oral-anal intercourse (anilingus).
  • Receptive manual-anal intercourse (insertion of finger or fist in anus of partner).
  • Substance use accompanying sex.
  • Tattooing or body piercing.
  • IDU and other drug use.

A substance use history should also be taken.

Travellers who have had unprotected sex with a new partner while travelling should be offered STI screening for chlamydia, gonorrhea, syphilis, HIV and HBV (if unvaccinated).Footnote 9 Hepatitis C virus (HCV) testing should be offered if the history reveals drug use, tattooing, body piercing, or other activities where sharing of contaminated equipment may have occurred (see Immigrants and Refugees chapter for more information). Health care workers should be aware that travellers may present with STIs rarely seen in Canada, such as chancroid, lymphogranuloma venereum (LGV) (see Chancroid and Lymphogranuloma venereum chapters). HIV testing should be accompanied by recommended counselling (see Human Immunodeficiency Virus Infections chapter).

Specimen Collection and Lab Diagnosis

  • Same as for all patients. See relevant chapters on specific infections.

Management and Treatment

  • Same as for all patients. See relevant chapters on specific infections.

Reporting and Partner Notification

  • Same as for all patients. See relevant chapters on specific infections.
  • Notification of partners abroad may pose a challenge but should be attempted in conjunction with local and provincial departments of health and the Public Health Agency of Canada.

Follow-up

  • Travellers who engage in high-risk sexual activities when travelling should be encouraged to undergo regular STI screening. Safer-sex and harm reduction counselling should continue to be emphasized. HIV, HBV and HCV testing should be scheduled following the window period, and adherence to safer-sex practices until that time may be indicated to prevent infection of current partners. HAV and HBV vaccination series should be completed if initiated prior to travelling.

References

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