Travel Health Information at Commercial Travel Websites

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was assessed through a review of the top 25 airline and 20 discount travel websites. Each site .... websites (“self-service, internet travel agents”), to deter- ..... Customer Care > International Travel > Traveler's Health (link to www.cdc.gov/travel).
Travel Health Information at Commercial Travel Websites Lynn L. Horvath, Clinton K. Murray and Herbert L. DuPont Background: Internet travel purchases accounted for 10% of the travel industry revenue generated in 2001. To ensure that travelers remain healthy during excursions to developing countries, travel health information needs to be available at commercial travel websites. We evaluated the current availability of travel health information at these websites. Methods: The existence, adequacy and ease of access of the travel health information provided on commercial travel websites was assessed through a review of the top 25 airline and 20 discount travel websites. Each site was examined to determine whether it provided general information, such as jet lag, or international travel health information, such as malaria prophylaxis. We also assessed hyperlinks to external travel health information websites, such as the CDC, when provided. Results: Travel health information was not available at 20 (44%) commercial travel websites, including 36% of airline and 55% of the discount travel websites. Twenty-eight percent of airline websites contained general information only, 8% links only, and 28% general and international information. Travel health information available at discount travel websites included 10% general only, 30% link only, and 5% general and international information. On average, it took three clicks to access travel health information. Keywords clicked to access travel health information frequently did not obviously refer to health. Each of the six travel health website links provided accurate vaccine and travel health information. However, several links lacked disease-specific maps and details of disease risk (i.e. seasonal and regional variations of malaria risk). Conclusions: Travel health information on commercial travel websites may be the only data available to travelers purchasing online. The information currently provided is generally inadequate. Ideally, commercial travel websites would provide uniform information that is accurate and easily accessible. Internationally recognized organizations should consider establishing guidelines for the information provided on commercial travel websites.

It is estimated that more than 61 million households in the US purchased airline tickets and accommodations online in 2002. This accounted for approximately 10% of the $20 billion dollar (US) travel industry, and this share is expected to increase.1 Most of these purchases were made by travelers looking for airline tickets and hotel reservations discounted specifically for internet consumers.

For many travelers seeking bargains online, this will be their only opportunity to review pretravel health advice. Significant illness can occur during travel, especially in developing countries.2 Travel industry professionals, such as travel agents, traditionally have the earliest knowledge of a traveler’s plans, and therefore can most appropriately direct referral for medical advice.3 Travel health information from these providers has been made available from within the travel industry (i.e. travel brochures) and via referral to health care professionals, including travel clinics, public health clinics, and general practitioners.4 Although most travel agents do understand the importance of referral to travel medicine professionals, this need is not uniformly recognized.5 This is evident in documented reports of traveler fatalities secondary to inaccurate advice given by travel agents.6 A pretravel evaluation by a travel medicine expert remains the most reliable source of advice to maintain traveler health. As travel purchases from travel industry professionals decrease and direct booking online increases, commercial travel websites will need to educate travelers about healthy travel and direct them to the appropriate travel health resources. Two travel medicine research teams have attempted to evaluate the travel health resources available online, but these approaches focused on familiarizing health care providers with the physician-oriented resources available on the internet.7,8 The travel health resources available

Lynn L. Horvath, MD, and Clinton K. Murray, MD: Department of Medicine, Infectious Disease Service, Brooke Army Medical Center, Fort Sam Houston, Texas; Herbert L. DuPont, MD: Internal Medicine and Travel Medicine, St Luke’s Episcopal Hospital, Houston, Texas; Center for Infectious Diseases, University of Texas, Houston School of Public Health, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas. The authors had no financial or other conflicts of interest to disclose. The views expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government. Reprint requests: Lynn L. Horvath, MD, Brooke Army Medical Center, Infectious Disease Service (MCHE-MDI), 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234. J Travel Med 2003; 10:272–279. 272

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to the common traveler have not been thoroughly evaluated. Sing et al. looked specifically at the information available to travelers on the websites of 73 international airlines in July 1999. Their search discovered only seven websites that provided health information, six of which addressed health problems that might be encountered when traveling to high-risk tropical countries.9 With increasing travel purchases online, travel health information provided on the internet, preferably at the website where the purchases are made, could be helpful to ensure healthy travel. Internet travel health information must be complete and accurate, but also easily accessible and understood. This will provide travelers with an awareness of the health risks associated with travel and provide them with appropriate referral information. We evaluated commercial travel websites, consisting of both airline and the increasingly popular discount travel websites (“self-service, internet travel agents”), to determine if these sites are currently providing appropriate travel health information.

ization (WHO). The number of clicks and the keywords clicked to locate the travel health information were recorded to determine the ease of access to information at each website. The information provided at both the commercial travel websites and travel health links was assessed for the accuracy of the content provided. In some instances, websites were interactive, and detailed information could be obtained about specific destinations. In those cases, we assessed the adequacy of the information provided using Thailand as our travel destination,looking specifically at recommendations for malaria and travelers’ diarrhea. Thailand is known to have regional variations for malaria risk, specifically with increased risk and mefloquine resistance along the Thai–Myanmar border. Travelers’ diarrhea secondary to Campylobacter spp. in Thailand may be resistant to fluoroquinolone therapy, necessitating the use of other antimicrobial agents such as azithromycin.

Materials and Methods

We reviewed the websites of the top 25 airlines, and they are listed here in descending order:

Forty-five commercial travel websites were evaluated during December 2002. Websites reviewed included the top 25 airlines, based upon the total number of passengers during the period from January to October 2002, as determined by Air Transport World (www. atwonline.com). Twenty discount travel websites were additionally evaluated. These websites included the top six discount travel websites, based upon website activity during the period from January to June 2002, as determined by comScore Media Metrix (www.comscore. com). The 14 remaining discount travel websites were identified through a Google websearch using the following keywords:travel,travel purchase and travel reservations. Each website was evaluated independently by two infectious disease physicians to determine whether travel health information was available. If travel health information was present,it was placed into one of three categories: onsite general travel health information, onsite international travel health information, or hyperlink (link) to a separate travel health information website. General travel health information included recommendations to avoid a variety of complications of travel, including deep venous thrombosis, jet lag and motion sickness. International travel health information included recommendations regarding the more important risks associated with the specific destination, including recommended immunizations, malaria prevention, and treatment of diarrhea. The presence of a link indicated that an icon at the commercial travel website immediately connected the user to a travel health website such as the Centers for Disease Control and Prevention (CDC) and the World Health Organ-

Results

American (www.aa.com), United (www.united.com), Delta (www.delta.com), Northwest (www.nwa.com), British Airways (www.britishairways.com/ travel/home/public/en_us), Air France (www.airfrance.com/us), Continental (www.continental.com), Lufthansa (cms.lufthansa.com/de/fly/en/homepage), Southwest (www.southwest.com), Air Canada (www.aircanada.ca/e-home.html), Singapore (www.singaporeair.com/saa/app/saa), USAirways (www.usairways.com), JAL (www.japanair.com/e/), Qantas (www.qantas.com.au/regions/ dyn/home/qualifer-region-au), KLM (www.klm.com/nl_en/index.jsp), Cathay Pacific (www.cathaypacific.com/intl/0,,,00.html), Iberia (www.iberia.com/iberia_us/home.jsp), Korean (www.koreanair.com), America West (www.americawest.com/homelE.asp), Thai International (www.thaiair.com), Emirates (www.emirates.com), SAS (ibp2.scandinavian.net/planandbook/ searchAvailView.asp?MKT=US), Alitalia (www.alitaliausa.com), Varig (www.reservaciones.com/airlines/varig.shtml), and China Airlines (www.china-airlines.com/ en/index.htm). Southwest is the only airline among the top 25 airline carriers that provides no international destinations.

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Additionally, 20 discount travel websites were reviewed for travel health content. The top six discount travel websites reviewed are listed here in descending order: Expedia (www.expedia.com), Travelocity (www. travelocity.com), Trip Network (www.trip.com), Orbitz (www.orbitz.com), Priceline (www.priceline.com), and Hotwire (www.hotwire.com).The remaining 14 discount travel websites reviewed are listed in alphabetical order: Airfare Planet (www.airfareplanet.com), Air Gorilla (www.airgorilla.com), Airline Tickets (www.airlinetickets.bz), American Express (www.itn.net/cgi/get?itn/pl/amexconsumer/index), Cheap Tickets (www.cheaptickets.com), CIAT (www.cheap-international-airline-tickets.com), EZ Ticket Sales (www.ezticketsales.com), Faremax (www.faremax.com), Get Me Ticket (www.GetmeTicket.com), One Travel (www.onetravel.com),

Travel (www.travel.com), Travel Discounters (www.travelDiscounters.com), Travel Hero (www.travelhero.com), and Travel Interface (www.travelinterface.com). Thorough review of the commercial travel websites revealed that 20 of 45 (44%) did not contain any travel health information. Of the 56% of websites containing some form of travel health information, airline websites were more likely to provide information than discount travel websites; 16 of 25 (64%) and nine of 20 (45%), respectively. The travel health information provided varied widely, and a synopsis of the travel health information available on the websites studied is presented in Table 1. Nine of 45 (20%) websites contained general travel health information only; these included seven of 25 (28%) airline and two of 20 (10%) discount travel websites. Eight of 45 (18%) websites contained no travel health information at the actual website,but had an icon on the site that linked the user directly to a travel health website. Most links were

Table 1 Travel Health Information Available on Airline and Discount Travel Websites None Airline websites Alitalia America West China Airlines Emirates JAL Lufthansa Southwest Thai International Varig

General Only * Air Canada Iberia Korean Qantas SAS Singapore Air USAirways

Discount travel websites Airfare Planet American Express Air Gorilla Get MeTicket Airline Tickets CIAT Expedia Hotwire One Travel Priceline Travel Travel Discounters Travel Interface

Link Only †

General and Link

General and International ‡

General, International and Link

United Northwest

Air France American § Cathay Pacific

Continental KLM

British Airways Delta

Cheap Tickets EZ Ticketsales Faremax Orbitz Travel Hero Trip Network

None

Travelocity

None

*General only: topics typically included are deep venous thrombosis (DVT), jet lag and motion sickness. Note: Of all the commercial travel websites containing general travel health information, prevention and/or treatment of DVT, jet lag and motion sickness were discussed on 82%, 76% and 29% of the websites, respectively. †

Link only: website contained an icon that directly linked to one of the following websites: www.cdc.gov/travel, www.fitfortravel.scot.nhs.uk, www.Frommers.com, www.masta.org, www.travmed.com, or www.who.int/ith.



International: topics generally included recommendations for immunizations and avoidance of insect-borne diseases. Note that no websites contained international information only.

§

The American Airlines website contained a link to www.cdc.gov; this required an additional click on “Traveler’s Health” to access travel health information.



The Travelocity website covered general and international health topics extensively. The website additionally had icons for CDC and WHO links, both which were not operational.

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to the CDC travel website, but six different links were encountered, including CDC (www.cdc.gov/travel), Fit For Travel (www.fitfortravel.scot.nhs.uk), Frommer’s (www.frommers.com), MASTA (Medical Advisory Services for Travellers Abroad) (www.masta.org), Travel Medicine (www.travmed.com), and the WHO (www. who.int/ith). Two of 25 (8%) airline and six of 20 (30%) discount travel websites provided only a link to another travel medicine website. Three of 25 (12%) airline websites provided both a link and general travel information. All eight (18%) websites that provided onsite international travel health information also provided general travel health information. These included seven of 25 (28%) airline and one of 20 (5%) discount travel websites. Interestingly, only 36% of airline websites and 15% of discount travel websites specifically recommended that travelers see a physician prior to international travel. Three commercial travel websites contained particularly thorough discussions of travel health information. Two airline websites (British Airways and Delta) contained general and international travel health information in addition to an operational link to another travel health website. The Travelocity website contained extensive coverage of general and international travel health topics; however, the icons for both the CDC and WHO links were not operational. We assessed the content of the health information provided by the website of each travel medicine link, and a summary of the findings is displayed in Table 2. Three of six websites (CDC, WHO and Travel Medicine) discussed the specific variations of malaria within Thailand, including resistance to mefloquine and recommended alternative chemoprophylaxis with either atovaquone– proguanil or doxycycline. Only one website (Travel Medicine) mentioned that Campylobacter-associated diarrhea may be resistant to fluoroquinolone therapy in Thailand and recommended azithromycin as an appropriate alternative therapy. The ease of access to available information was assessed utilizing both the number of clicks and ease of keyword recognition. A summary of the data on the number of clicks and keywords for airline and discount travel websites is presented in Tables 3 and 4, respectively. Overall, the average number of clicks required to locate travel health information was three, ranging from one to six. Three of the 45 (6%) websites, all discount travel websites, allowed the user to access travel health information with as little as one click. However, nine of the 45 (20%) websites required four or more clicks to access any travel health information. None of the 16 airline websites containing travel health information used keywords that would lead the user to believe that travel health advice will follow, although “Before You Fly” (Cathay Pacific) and “Trip Planning” (Air France) may imply this. It is

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the opinion of the authors that keywords such as “Flying with Us”(Qantas),“KLM Services”(KLM) and “Products & Services” (Singapore Air) give the user minimal indication that travel health information is soon to follow. The three discount travel websites that allowed access to travel health information with only one click also provided keywords that obviously referred to travel health information. The keywords were “Vaccinations” (EZ Ticket Sales), “Health Advisories” (Faremax), and “Surviving Jet Lag” (Get Me Ticket).

Discussion We evaluated commercial travel websites for the existence, accuracy and ease of access of travel health information. The existence of travel health information on these websites is truly important, as consumers spend an increasing percentage of their travel dollars online. Unfortunately, roughly half of the commercial travel websites that we studied provided no travel health information at all. An even smaller number of websites actually provided complete and accurate travel health information that was easily accessible. The travel health information at commercial travel websites must improve in order to allow travelers the best chance to maintain good health. Our concern is that commercial travel websites are for-profit travel companies, and they may not even be aware of the potential impact they can have on the health of travelers. Several companies have created commercial travel websites with outstanding access to travel health information, and all other commercial travel websites should strive to match and even improve upon the information provided by these websites. Travelocity was the most complete of the discount travel websites, and has the potential to improve even further with operational CDC and WHO links. It should be noted, however, that the authors of this paper feel that even the CDC and WHO websites may not be the best resource for the general traveler, as these sites are cumbersome to navigate for the novice, and use language that is at the level of a medical professional. Two airline websites (Delta and British Airways) provided extensive general and international travel health information on their website, in addition to operational travel health links. The Delta website further distinguished itself with its link to Travel Medicine (www.travmed.com), an outstanding travel health website geared specifically for travelers. We felt that this site was thorough, accurate and easy to both understand and use. However, all three of the best commercial travel websites (Travelocity, Delta and British Airways) could still improve the ease of access to the information provided.

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Table 2 Content of Travel Health Links

Number of links † Target audience Medical care List of travel clinics near home List of health care providers abroad Travel insurance Maps Maps included Interactive maps (click on region) Maps with disease risks General travel health information Altitude sickness DVT/PE Jet lag Motion sickness Pregnant travelers Sun protection STDs International travel health information Safe food and water recommendations Travelers’ diarrhea therapy Prevention of insect exposures Immunizations General recommendations Country-specific Malaria General information Country-specific Variations within country noted Medications Chemoprophylaxis Emergency therapy Side effects/ precautions Other tropical disease risks Outbreak information

Fit For Travel

Frommer’s *

MASTA

Travel Medicine *

4 Professionals and travelers

1 Travelers

1 Travelers

1 Travelers ‡

1 Travelers













 

 

 

 

 

 













 

 

 §

 

 

 

      

      

      

      

      

      





































 

 

 

 

 

 

 

 

 

 

 

 













 

 

 

 

 

 













 

 

 

 

 

 

CDC

WHO

12 Professionals

*Frommer’s and Travel Medicine are both commercially oriented travel websites; travel health information is provided at both websites, but they both sell travel and travel-related items. The primary goal of this link is not to provide travel health information, though basic country-specific travel health information was available at the website. †

Number of links refers to the number of times this website was referred to during our study; note that several commercial travel websites referred users to more than one link.



Health care providers can subscribe to this site to obtain additional travel health information.

§

The maps at this website were outstanding–specifically with highlighting of malaria risk regions within each country.

PEpulmonary embolism.

5 5 6

Air France*

American

Northwest

Travel Planning > Health Tips Before You Fly > Travel Smart Flying with Us > Your Health Travel Information > Travel Help & Resources > Personal Health Travellers’ information > Health and well being > Health and Medical Information Travel Center > Special Needs > Personal Health Travel > Healthy Travel Tips > Before Your Trip and During Your Flight Travellers’ Guide > Useful Information > How to make a trip more comfortable and healthy KLM Services > Health > Fit to travel Travel info > In the Air > Well-being Products & Services > For Your Travel Comfort > Deep Vein Thrombosis Travel Planning > International Travel Information > Tips for Healthy Travel Trip Planning > Trip Preparation > Health > Presentation or Health on board Travel Guide > Select Destination Region > Select Destination City > Travel Basics

Destination Information > Immunizations (link to www.cdc.gov/travel) Travel > Healthy Travel Tips > www.cdc.gov/travel or www.travmed.com Travellers’ information > Health and well being > Travel clinics > www.fitfortravel.scot.nhs.uk Before You Fly > Travel Smart > Extra Care > Center For Disease Control (link to www.cdc.gov/travel ) or MASTA (link to www.masta.org ) Trip Planning > Trip Preparation > Health > Vaccination > Who Health Organization (link to www.who.int/en ), Center For Disease Control and Prevention (link to www.cdc.gov ) and Center For Disease Control and Prevention Traveler’s Health (link to www.cdc.gov/travel ) Travel Information > Travel Help & Resources > Visa/Immunization (link to www.travel.state.gov/foreignentryreqs.html ) > Centers for Disease Control and Prevention (link to www.cdc.gov ) > Travelers’ health Travel Planner >Destination Guide > Details about your destination > Type in destination > Planning a trip (link to www.Frommers.com ) > Health & Safety

Traveller’s Information > Health and well being > Health and Medical Information Travel > Healthy Travel Tips > At Your Destination KLM Services > Health > FAQ > Malaria or Immunizations Travel Center > Destination Guide > Passport, Visa & Health Requirements > Type in destination > Health Information

Keywords

*Air France links to the WHO homepage (www.who.int/en), not the travel information page. The user must click on “Travellers’ Health” to get to the international travel and health page (www.who.int/ith).

2 2 2 3 3 3 3 3 3 3 3 3 4 4

2 3 4 4

Travel health links United Delta British Airways Cathay Pacific

General travel health information Air Canada Cathay Pacific Qantas American British Airways Continental Delta Iberia KLM SAS Singapore Air USAirways Air France Korean

3 3 4 5

Clicks

International travel health information British Airways Delta KLM Continental

Website

Table 3 Number of Clicks and Keywords Used to Locate Travel Health Information on the Top 25 Airline Websites

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Table 4 Number of Clicks and Keywords Used to Locate Travel Health Information on 20 Discount Travel Websites Website International travel health information Travelocity Travel health link EZ Ticket Sales Faremax

Clicks

Keywords

4

Guides & Advice > Traveler Advice > Healthy Travel > Health Tips*

1 1 2

Vaccinations (link to www.cdc.gov/travel) Health Advisories (link to www.cdc.gov/travel) US Dept of State (link to www.state.gov/travel > Traveler’s Health-CDC (link to www.cdc.gov/travel) and Traveler’s Health-WHO (link to www.who.int/ith) Resources > Travel Health Guidelines (link to www.cdc.gov/travel) Customer Care > International Travel > Traveler’s Health (link to www.cdc.gov/travel) Guides & Advice > Traveler Advice > Healthy Travel > Creepy, Crawly Critters: Avoiding Insect Encounters > World Health Organization and Centers for Disease Control (links to WHO and CDC websites were not operational) Travel Resources > Travel Tips > Intl Travel > US Dept of State (link to www.state.gov/travel > Traveler’s Health-CDC (link to www.cdc.gov/travel ) and Traveler’s Health-WHO (link to www.who.int/ith ) Travel Resources > Travel Tips > Intl Travel > US Dept of State (link to www.state.gov/travel > Traveler’s Health-CDC (link to www.cdc.gov/travel ) and Traveler’s Health-WHO (link to www.who.int/ith )

Travel Hero Orbitz Travelocity

2 3 5

Trip Network

5

Cheap Tickets

5

General travel health information Get Me Ticket American Express Travelocity

1 4 4

Surviving Jet Lag Travel Resources > Travel Essentials & Advice > Travel Tips > Personal Safety † Guides & Advice > Traveler Advice > Healthy Travel > Health Tips*

*Travelocity Health Tips: extensive general and international travel health information, including sun exposure, heat exposure, jet lag, altitude sickness, food and water precautions, insect exposure, water exposure, first aid and travel health insurance. †

American Express Personal Safety: general information about travel health insurance, food and water precautions.

In order to ensure that travelers have adequate health information before travel, it is essential that 100% of commercial travel websites provide travel health information. Ideally, consumers should be able to access the travel health information on these websites from the home page, with one click on an obvious keyword, such as “Traveler’s Health”. Clicking this keyword should display a page with a selection of both general and international travel health topics; the page should also provide the capability to access travel health links and obtain accurate country-specific recommendations. It is of the utmost importance that commercial travel websites ensure that the information provided is both accurate, up-to-date and easily understood by the non-medical professional. Our study of commercial travel websites revealed that much improvement in this area is needed. International organizations such as the International Society of Travel Medicine (ISTM) and the World Health Organization, and national organizations such as the American Society of Tropical Medicine and Hygiene and the Centers for Disease and Prevention (CDC), should consider establishing guidelines for the travel health content provided by commercial travel websites. This would help new as well as existing commercial travel websites to provide travel

health information to their customers in a uniform and accurate manner. This would bring us one step closer to ensuring healthier travel for all travelers. Acknowledgments This review of commercial travel websites was conducted without monetary support from any of the companies named within this manuscript. It should be noted that this review of the travel health information available on commercial travel websites was completed during a discrete period of time in December 2002. The information available on the internet is constantly changing, and these websites are no exception. It is therefore possible that information available at these websites will have changed by the time of publication. These data were presented in abstract and poster form (PO12.06) at the 8th Conference of the International Society of Travel Medicine in New York, NY, May 2003. References 1. Tedeschi B. For the web generation, travel is self-service. New York Times, 20 October 2002:Sect. E:7 (col. 1).

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2. Steffen R, Rickenbach M, Willhelm U, et al. Health problems after travel to developing countries. J Infect Dis 1987; 156: 84–91. 3. DuPont HL, Steffen R, eds. Textbook of travel medicine and health, 2nd edn. Hamilton, Ontario: BC Decker, 2001. 4. Leggat PA. Sources of health advice given to travelers. J Travel Med 2000; 7:85–88. 5. Provost S, Gaulin C, Piquet-Gauthier B, et al. Travel agents and the prevention of health problems among travelers in Quebec. J Travel Med 2002; 9:3–9. 6. Hall P, Fojtasek M, Pettigrove J, et al. Fatal yellow fever in a traveler returning from Amazonas, Brazil, 2002. MMWR 2002; 51:324–325.

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7. Freedman DO. Keeping current: travel medicine resources available on the internet. Infect Dis Clin North Am 1998; 12:543–547. 8. Keystone JS, Kozarsky PE, Freedman DO. Internet and computer-based resources for travel medicine practitioners. Clin Infect Dis 2001; 32:757–765. 9. Sing A, Salzman JR, Sing H, Sing D. Evaluation of health information provided on the internet by airlines with destinations in tropical and sub-tropical countries. Commun Dis Public Health 2000; 3:195–197.

Is a travel kit necessary? Or should travellers use any one of the colored liquids ‘to cure any type of disease’, that is the question. RKES, Benin.