Dial M for mosquito

ITIJ 161, June 2014

The growth and spread of mosquito-borne diseases throughout the world has meant areas that were considered relatively safe destinations for travellers are now under threat from infections not previously seen before. Robin Gauldie reports – with a strong stomach


With the World Health Organization (WHO) warning of the emergence of new vector-borne diseases in areas such as Europe and the Caribbean, and some experts claiming that a new pandemic is only a matter of time – the ebola outbreak in West Africa continues to escalate, and MERS numbers have increased sharply in recent weeks – infectious diseases are a major issue for travel insurers and assistance companies. Massive expansion of holiday travel to areas suffering from outbreaks of tropical diseases has also led to many more travellers being exposed to the risk of infections from mosquitoes carrying malaria and dengue fever, or diseases such as leishmaniasis and encephalitis.

But while these exotic illnesses can threaten lives, simple gastroenteritis is still by far the biggest cause of ruined holidays and the resultant claims for medical treatment. Such infections are less common than they used to be in southern European destinations, according to the experts, but are far from unusual elsewhere.  


Tummy troubles

“It is fair to say that in the past, stomach upsets on foreign holidays were regrettably common, almost to the point of being seen as part of the holiday experience,” said Sean Tipton, media relations manager at the British travel industry organisation ABTA – The Travel Association. “‘Delhi belly’ or ‘Montezuma’s revenge’, to name just two [are common], and eating new, exotic food was often part of the cause,” he continued, adding: “Issues with water quality and food hygiene management and also the combination of high temperatures, dehydration and increased alcohol at times continue to play their part.”   

ABTA and its members have worked closely with destinations to review improve standards and deliver training to the hospitality sector, Tipton says. “Legislation from the European Commission has also gone a great way towards improving matters in relation to food and drinking water safety at holiday destinations within the European Union,” he adds.

Ian Brown, a partner at the British law firm Stones Solicitors and a member of its travel, tourism and insurance team, tends to agree with Tipton. “As a firm, we do see a number of food poisoning cases, but I would not say that these have particularly increased in recent times,” he told ITIJ. However, if destinations that were considered exotic as recently as the 1970s have cleaned up their act, millions more people worldwide now travel to medium- and long-haul destinations where they may be exposed to a range of ailments.

The boom in all-inclusive resort holidays is widely blamed for a number of cases in which large numbers of guests fall ill at the same resort, with high-profile cases in recent years of tour operators paying compensation to guests at resorts in destinations including the Dominican Republic, Turkey and Egypt.

Anne Thomson, head of travel law at Your Holiday Claims, commented: “Unfortunately, particularly in all-inclusive hotels, poor food and hygiene standards, particularly in foreign countries, can cause outbreaks of illness. Food poisoning, campylobacter, salmonella and cryptosporidium are amongst the most common causes of holiday illnesses.”

All inclusive resorts (and the tour operators which sell them) find it hard to deny compensation claims arising from outbreaks of food poisoning because guests rarely leave the property during their stay and take all their meals within the hotel.   


Developing world dangers

Since the 1980s, there has been a worldwide surge in travel from wealthier tourism source markets such as Europe, North America and Australasia to the developing world. Inevitably, that exposes more travellers to a widening spectrum of diseases that range from the merely unpleasant to the potentially lethal.

While the vast majority of European travellers take their holidays or business trips close to home, in countries with fairly low health risks, Australians are more likely to visit tropical destinations in southeast Asia. Travel insurer Cover-More Australia notes that Bali is the second-most-popular destination for Australian travellers behind the US. In 2012, the company stated, 317,809 Cover-More policyholders travelled to Bali and 44 per cent of the claims made by those policyholders were for illness or injury. The most common claims for illness or injury in Bali are for gastroenteritis, ear, nose and throat conditions, respiratory infections, trauma (injuries) and cardiac conditions.

“The hospitals we liaise with on behalf of our policyholders are well-equipped to deal with tropical illness and diseases, but it is worth noting that not all hospitals offer the same standards, particularly in the rural areas,” said a Cover-More spokesperson.

A report by the US Centers for Disease Control and Prevention (CDC), Travel-associated Illness Trends and Clusters, 2000-2010, cites World Tourism Organisation (WTO) statistics indicating that trips to developing regions have risen from 31 per cent of all travel in 1990 to 47 per cent in 2010, and trips to the Asia Pacific region, Africa, and the Middle East doubled in the same decade. More than half of all travellers to developing countries become ill while abroad, according to the WTO. Most of these suffer from relatively mild gastrointestinal infections caused by microbial contamination of food and water, but eight per cent have symptoms severe enough to warrant medical attention.

Last year, analysis by the US CDC of 42,000 tourists from North America, Europe and elsewhere who sought medical care for travel-related infections during 2000 to 2010 found that there was more than a 50-per-cent increase in such illnesses over the course of the decade. Mosquito-borne illnesses such as malaria, dengue fever, and chikungunya also rank among the most common problems encountered by travellers, according to the survey. In some African countries, malaria infections have fallen because of improved mosquito control, but dengue fever worldwide is on the increase.

Meanwhile, diseases that have traditionally been associated with tropical or sub-tropical countries may be migrating to European holiday destinations. In 2012, more than 2,100 cases of dengue fever were reported on the Portuguese island of Madeira. These included 78 cases involving travellers from other European countries – including the UK, Germany, mainland Portugal and France.

The World Health Organization (WHO) is warning that new vector-borne diseases are emerging in Europe, while diseases that were thought to have been eliminated are making a comeback. Climate change, environmental change, and political and social disruption in some countries are factors in the resurgence of malaria in countries in which it had disappeared, as well as the incidence and distribution of diseases such as Crimean-Congo haemorrhagic fever, tick-borne encephalitis, Lyme disease and Chagas disease in WHO’s European region. Concern has been voiced that Syria’s drawn-out civil war is a factor in the reappearance of polio in Syrian children in refugee camps in both Syria and Turkey, and that the disease could spread beyond Syria’s borders.

“War and conflict are both spreaders of infectious diseases and barriers to elimination programmes,” confirmed Dr Charlie Easmon, of UK-based Your Excellent Health Service. If polio were to spread from Turkey’s remote southeastern border region towards the country’s mass tourism resorts, it could worry travel insurers and medical assistance companies. However, Turkish authorities are already reacting to the threat with a well-organised vaccination campaign.


Little blighters

According to the European CDC, by March 2014 almost 8,000 suspected cases of chikungunya had been reported from the Caribbean in the first known outbreak of the disease in the Americas. Chikungunya – a potentially fatal, mosquito-borne disease endemic in much of Africa and southern Asia – has reached epidemic proportions since 2004, according to WHO. The Aedes mosquito, which carries Chikungunya, has spread to parts of Europe and the Americas. In 2007, disease transmission was reported for the first time in a localised outbreak in northeast Italy. In 2010, three cases were reported in southeast France. Some insurers include WHO advice on travel to areas affected by outbreaks of communicable diseases in their policies, and will not cover people who travel to countries affected by that advice, even if government departments such as the UK Foreign and Commonwealth Office have not advised against travel, notes Bronwen Courtney-Stamp, partner and head of travel, tourism and insurance team at Stones Solicitors. Furthermore, some tropical diseases are what might be described as ‘slow-burning’, with symptoms that may not present until months or even years after the person insured returns home, which inevitably complicates the claim, or potential for one. Dr Charlie Easmon says that, in addition to malaria, serious or fatal illnesses that may result in a late diagnosis include bilharzia schiatosomiasis, presenting as frequent urine infections, or bladder contraction or blood in urine sometimes 10 years later than the original infection; giardia, causing years of gut problems diagnosed as irritable bowel syndrome; rabies presenting months after bites; tuberculosis, causing persistent cough, weight loss and night sweats; and Japanese encephalitis causing non-specific nervous system problems. 
“With the exponential rise in travel and a limited number of travel health and tropical medicine specialists, the problem will only increase,” he says. “Diagnosis is a problem because general practitioners expect horses, not zebras.”

While increases in the number of travellers infected by exotic diseases may be a cause for concern, the travel insurance industry’s biggest bugbear is more mundane. Stomach problems make up more than 15 per cent of all travel insurance claims by British insureds, according to a sampling by AXA in September 2013. The insurance company’s survey also highlighted huge differences in the costs of treatment for such complaints in popular holiday destinations. AXA estimated that a typical two- to three-day hospital stay in France – the cheapest of 20 destinations studied – would cost around £2,000. The same care and treatment could cost around £3,000 in Barbados, £5,000 in Turkey and up to £20,000 in the US, according to the research. 

“The US was shown to charge more than twice as much as many other countries for basic healthcare, meaning that people without insurance may well end up paying medical bills that run into many thousands of pounds,” commented David Vincent, head of travel at AXA.

It should be noted, however, that an earlier survey of 10 holiday countries carried out by Sainsbury’s Travel Insurance and based on claims made in 2010, rated Greece as the destination where medical bills were cheapest, averaging £422, while the average bill in the US was £4,726.   

AXA reckons that some 15 per cent of the travel insurance claims it receives derive from stomach problems. With treatment costs estimated roughly at £2,000 per patient, and based on figures from the Association of British Insurers that showed 337,000 claims from UK clients in 2012, diseases such as gastroenteritis could be costing British insurance and assistance companies around £10.1 million annually.

Hilary Simons, senior specialist nurse at the UK National Travel Health Network and Centre (NaTHNaC), and the Liverpool School of Tropical Medicine, believes that there may be a need for more co-operation between organisations such as NaTHNaC. “We appreciate the importance of moving towards a closer dialogue with companies which insure travellers and hope to address this in the near future,” she says. What they do already, she says is advise, pre-travel, about travel related risks, and alert health professionals to current health topics (including disease outbreaks and changes in disease epidemiology) via clinical updates on its website. 

“In addition,” added Simons, “we work with Public Health England and provide advice for health professionals relating to what to look out for in the traveller who returns from overseas (including Europe). This may be general advice, or very specific and linked to a disease outbreak.”

That kind of advice could also be vital for travel insurers who wish to limit their expose to claims. Dr Charlie Easmon warned that another global pandemic like the 2002-2003 SARS (severe acute respiratory syndrome) outbreak is ‘inevitable’, and he believes that insurers can best deal with such events not by trying to assess risk, but by modifying their underwriting to withhold coverage of travellers who visit known areas of infection. That should certainly give the travel insurance industry food for thought, although how to control the behaviour of insured travellers is still the million-dollar question!