Impact of COVID-19 on a Medium-Sized Travel Medicine Clinic in Eastern Pennsylvania, USA

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Rao, Mark C. Knouse This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4830164/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Mar, 2025 Read the published version in Tropical Diseases, Travel Medicine and Vaccines → Version 1 posted 10 You are reading this latest preprint version Abstract Background: The COVID-19 pandemic (COVID) disrupted international travel. We sought to determine the impact of the COVID-19 pandemic on patient volume, traveler demographics, and income of our travel clinic in Pennsylvania, USA. Methods: We extracted de-identified pre-travel data on 3,510 pre-travel consultations for adults during: Pre-COVID-19 (January 2018-December 2019), Early COVID-19 (April 2020-March 2022) and Late COVID-19 (April 2022-March 2023). We compared traveler demographics, destinations, purpose of travel, medical conditions, and number of vaccinations administered over time, and we obtained our clinic’s revenue from our financial database (TruSource) from the Pre-COVID-19 period to the Early and Late COVID-19 periods. Results: We observed 84% and 85% relative decreases in traveler volume and revenue respectively from the Pre-COVID-19 to the Early COVID-19 period. The proportional decrease in volume was highest for travelers over 65 years of age, decreasing from 16–11%. Of those that sought care during Early COVID-19, proportionally fewer travelers had multiple co-morbid conditions and were taking chronic medications. Trip length increased and there was a significant proportional increase in travel to Africa. Travel to visit friends or family and for service work also proportionally increased during Early-COVID-19 versus Pre-COVID-19. Clinic volume and revenue began to increase in Late COVID-19 but did not return to Pre-COVID levels. Conclusions: The COVID pandemic resulted in a large reduction in patient volume and revenue in our academic-based Pennsylvania travel clinic. We saw substantial changes in our traveler demographics, destinations, as well as reasons and durations of travel. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction In early 2020, COVID-19, also known as Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), disrupted international travel for a variety of reasons. Governmental regulations contributed to this, and on March 19, 2020, the US instituted a Global Level 4 Health Advisory of “Do not travel” in an attempt to contain the pandemic and prevent its spread. 1 The degree of risk perception during pandemics varies among individuals, which may affect the decision to travel, destinations for travel, as well as the duration of international trips. 2 The impact of the pandemic on international travel and the travel-related industry was enormous. 3 For example, The International Civil Aviation Organization (ICAO) reported in April 2023 a 60% drop in total world passengers in 2020 compared with the 2019 baseline, and a 49% overall drop for the year 2021 compared to 2019. The corresponding revenue loss to the airline industry during calendar year 2020 as compared to 2019 was estimated at 372 billion in USD. 4 Prior to international travel, individuals may seek care and advice at a travel medicine clinic in order to mitigate health and safety risks at their destinations. These consultations typically include advice and education, vaccination, and the prescribing of chemoprophylaxis such as to prevent malaria. 5 , 6 As a medium-sized travel clinic in the eastern part of Pennsylvania, we sought to assess the impact of the pandemic on our travel clinic from multiple perspectives, including changes in the traveler demographics and the travel profile as well as the financial impact to the clinic. Methods Our travel clinic in Eastern Pennsylvania is located in the Lehigh Valley, serving the Valley population and some contiguous communities as the primary catchment base. This catchment base includes 910,000 local residents. 7 The travel clinic is embedded in a larger Infectious Diseases practice as a part of a large tertiary-care health network of 13 hospitals of various sizes that include many specialty residency training programs. Staffing the travel clinic are ten board-certified Infectious Diseases physicians and two Physician Assistants, the majority of whom have a Certification of Travel Health. 8 During the two years preceding the COVID-19 pandemic, our travel clinic generated approximately 3.7% of all of the Infectious Disease practice revenue (counting outpatient and inpatient consultations). Prior to the onset of COVID-19 our travel clinic performed on average 1,353 pre-travel visits/year. We submit our pre-travel data to the Global TravEpiNet (GTEN network), which is a de-identified national registry and database of travelers coordinated by Massachusetts General Hospital and supported by the U.S. Centers for Disease Control and Prevention (CDC). 9 GTEN data include variables such as traveler demographics, medical history, medications, travel itinerary, duration and purpose of travel, and vaccination information. 10 Clinicians offering these consultations verify this information, add detailed immunization history, input vaccines administered, enter prescribed medications and document specific counseling provided. Travelers who seek pre-travel counseling at our clinic are asked to pay the full consultation fee by cash or credit card at the time of the visit. The payment for any recommended vaccination is dependent on the traveler’s insurance coverage. Our clinic accepts all insurance types present in our region: HMO, PPO, Medicare, State funded plans (Medicaid), Veterans’ Administration, and private insurances. Patients without insurance coverage (self-pay) are expected to cover the costs of the vaccines themselves. Many insurances will cover certain vaccines, typically those in routine US Advisory Committee of Immunization Practice (ACIP) guidelines, for example measles-mumps-rubella (MMR), tetanus-diphtheria and acellular pertussis (Tdap), inactivated polio, and hepatitis A. However, many insurance plans do not include coverage for other vaccines including typhoid, yellow fever, rabies, Japanese Encephalitis, or cholera vaccines. For these latter vaccines, patients are expected to pay cash/credit card at the time of service. Many Medicare, state Medicaid, and HMO plans require that travelers receive some of their routine vaccines (e.g. hepatitis A, Tdap) at either their primary care provider, or at a retail pharmacy. For this study, we considered only data pertaining to adult ( > = 18 years) travelers visiting our clinic between January 2018 through March 2023. We assessed changes in traveler demographics, destinations (by WHO region and by country) 11 , duration and reasons for travel, and overall health during the three periods defined as Pre-COVID-19 (January 2018-December 2019), Early COVID-19 (April 2020-March 2022) and Late COVID-19 (April 2022-March 2023). We created a variable to indicate reasons of travel with mutually exclusive categories: leisure, humanitarian service work, business, research and education, visiting family and relatives in a country of origin (VFR) and other reasons (e.g., adoption, military service, adventure, gatherings) indicating a hierarchy. For example, if someone traveled for leisure and any other purpose of travel, they were categorized as having traveled for leisure. We used data on the number of medical conditions and the number of medications taken to characterize the overall health of the traveler. The number of vaccines given per patient were tabulated for each of the three time periods. The first confirmed case of COVID-19 seen in our network was in March of 2020. We censored January through March of 2020 as the pandemic had not yet arrived in our region. April 1, 2022 was set as the beginning of the Late COVID-19 period as this was the time when a second Omicron wave crossed much of the United States and overall COVID-19-related mortality began to decrease 12 . These same parameters were used to analyze the financial impact the clinic faced in terms of visit volumes and revenue during this period. To assess the impact on revenue, we reviewed data stored in our network’s financial database, TruSource (WebFOCUS). 13 This data was then compared with trends in the demographic data from travel consultations. This study was deemed non-human subject research by the Institutional Review Board at Lehigh Valley Health Network. Statistics Summary statistics (e.g., proportions) were obtained and bivariate analyses using a two-sided chi-square test were conducted to assess the significance of the difference in the distributions of the variables across the three time periods. All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC) and a two-sided p < 0.05 was considered significant. The revenue data were normally distributed as assessed by the Shapiro-Wilk test (p values of 0.63, 0.36, and 0.98 for Pre-, Early and Late COVID respectively). There was homogeneity of variances as assessed by Levene’s test for equality of variances (p = 0.4856). An omnibus one-way ANOVA was conducted to determine if quarterly revenue differed significantly across the three COVID periods defined as – Pre-COVID-19 (2018 and 2019, n = 8), Early COVID-19 (April 2020-March 2022, n = 8), and Late COVID-19 (April 2022-March 2023, n = 4). Tukey post hoc analysis was conducted to determine specifically in which quarters revenue differed significantly. Results Early COVID Period We reviewed 3,510 travel records. 2,663 from the 24 month Pre-COVID-19 period, 429 from the 24 month Early COVID-19 and 418 from the 12 month Late COVID-19 periods (Table 1 ). We observed an 84% decrease in travel clinic volume between the Pre-COVID-19 and Early COVID-19 periods (Fig. 1 ). There was a proportional decrease in travelers over age 65 years seen at the clinic (11%) in Early COVID-19 compared with Pre-COVID-19 (16%). The duration of travel increased during the Early COVID-19 period compared with Pre-COVID-19. 62% of travelers seen during Early COVID-19 were traveling for 14 days or longer, compared with 49% Pre-COVID-19. 18.5% of travelers seen during Early COVID-19 were traveling for 28 days or longer, compared with 12% Pre-COVID-19. The most striking proportional change in destination was to Africa, with 77.2% of all travelers seen during early COVID-19 traveling to Africa, versus 47.6% pre-COVID-19 (Table 1 , Fig. 2 ). We saw a 10.5% absolute increase (300% proportional increase) in VFR travel 14 and 3.5% absolute increase (17.5% proportional increase) in humanitarian service work (p < 0.001) during the Early COVID-19 period with a corresponding absolute 6.4% drop in leisure and 6.6% drop in business travel (Fig. 3 ). Table 1 Traveler’s Demographics, Destinations, and Duration of Travel Across the Three Periods of COVID-19 Characteristics Pre- N = 2663(75.9%) Early Post- N = 429 (12.2%) Late Post- N = 418 (11.9%) N = 3510 Gender ( p = 0.773) Male 1159 (43.5%) 194 (45.2%) 186 (44.5%) Female 1504 (56.5%) 235 (54.8%) 232 (55.5%) Age (p 65 427 (16.0%) 47 (11.0%) 99 (23.7%) Duration of Travel (p < 0.0001) 28 days 320 (12.0%) 79 (18.5%) 49 (11.7%) Region of Travel Africa (p < 0.0001) 1267 (47.6%) 331 (77.2%) 200 (47.8%) Americas (p < 0.0001) 913 (34.3%) 78 (18.2%) 110 (26.3%) Southeast Asia (p < 0.0001) 313 (11.8%) 16 (3.7%) 67 (16.0%) Western Pacific (p = 0.0006) 271 (10.2%) 19 (4.4%) 36 (8.6%) Eastern Mediterranean (p = 0.2234) 131 (4.9%) 22 (5.1%) 29 (6.9%) Europe (p = 0.1766) 104 (3.9%) 11 (2.6%) 21 (5.0%) Reason for Travel (p < 0.0001) Leisure 1317 (49.5%) 185 (43.1%) 239 (57.2%) Humanitarian Service Work 533 (20.0%) 101 (23.5%) 63 (15.1%) Business 368 (13.8%) 31 (7.2%) 32 (7.7%) Research/Education 291 (10.9%) 35 (8.2%) 37 (8.9%) VFR 92 (3.5%) 60 (14.0%) 28 (6.7%) Other 62 (2.3%) 17 (4.0%) 19 (4.5%) Number of Pre-existing Medical Conditions (p = 0.0001) 0 641 (24.1%) 111 (25.9%) 69 (16.5%) 1 720 (27.0%) 124 (28.9%) 94 (22.5%) 2 592 (22.2%) 98 (22.8%) 113 (27.0%) > 2 710 (26.7%) 96 (22.4%) 142 (34.0%) Number of Current Medications Taken (p 2 811 (30.5%) 118 (27.5%) 177 (42.3%) Number of Vaccinations received (p 2 741 (27.8%) 102 (23.8%) 71 (17.0%) Supplementary data Supplementary data are available at Tropical Diseases, Travel Medicine, and Vaccines online. Regarding traveler health, during the Early COVID-19, there was a 4.2% decrease in the number of travelers with 2 or more medical conditions (proportional 16% decrease) and a 4.3% absolute increase in number of travelers taking none or only one medication (p < 0.0001). Vaccinations received per traveler during Early COVID-19 decreased from Pre-COVID-19; with 8.2% more travelers receiving zero vaccines and a 4% decline (proportional 14% decline) in travelers receiving 2 or more vaccines (Table 1 ). In terms of volume and revenue, COVID-19 resulted in an 84% drop (from an average 338 visits per quarter to 52 visits per quarter) in travel patient volumes, and a corresponding 85% proportional revenue drop for the travel clinic per quarter in the Early COVID-19 period from the Pre-COVID-19 period (Fig. 1 , S1). The travel clinic’s share of revenue in the Infectious Diseases practice dropped to < 1% during the COVID-19 pandemic and had not recovered to the Pre-COVID-19 levels by March 2023. By March 2023, quarterly clinic revenue [mean ± standard deviation] was still at only 28% of Pre-COVID-19 values, (Pre-COVID-19 [ $ 32,630.00± $ 4,356.58]; Early COVID-19 period [ $ 5,014.38± $ 2,796.09]; Late-COVID-19 period [ $ 9,044.00± $ 3,217.58] (p < 0.001). All individuals in this assessment paid for their pre-travel consultation aspect of the bill at the time of service throughout the three periods. Review of the traveler’s insurance coverage for vaccinations showed that there was a significant increase in self-pay (uninsured) individuals from the Pre- to Early COVID-19 periods (20.6% and 32.2% respectively) (p < 0.001), while those with commercial insurance showed a significant decrease from Pre- to Early COVID-19 (55.5% and 45.4% respectively) (S3). Late-COVID-19 Period During the Late COVID-19 period, there was an increase in travelers over 65 years of age (24%) versus Early COVID-19 (11%) and Pre-COVID (16%), and a reduction in trips longer than 28 days (11.7%) versus early COVID-19 (18.5%) and Pre-COVID-19 (12%) (Table 1 ). Travel to Africa as a proportion of clinic visits also fell appreciably (47.8%) versus early COVID-19 (77.2%) returning to Pre-COVID-19 proportion (47.6%). Using fewer medical conditions and fewer medications as a surrogate for healthier travelers, we saw generally healthier travelers in the Early COVID-19 period as compared to the Pre-COVID-19 period (Table 1 and S4, S5, S6). Vaccination uptake also changed significantly as there was an increase in the proportion of travelers who took no vaccinations from the Pre-COVID-19 period through the Late-COVID-19 period (6.5–20.8%) continuing on an upwards trend, while the proportion of individuals taking over 3 vaccines dropped significantly across the three periods from 27.8–17% (p < 0.0001) (Table 1 , Fig. 4 ). During both COVID-19 time periods, inpatient Infectious Diseases consultation requests increased dramatically (absolute increase of 57.4% from calendar year 2019 to 2020 and 7.9% from 2020 to 2021). Discussion Our retrospective record review revealed that the COVID-19 pandemic resulted in a large drop in travel clinic volumes and associated revenue from the Pre-COVID period and that these decreases were still present in the Late COVID-19 period although increases were occurring. This corresponds to the large decrease in international travel numbers due to travel restrictions and concerns about contracting COVID. Although our volume of inpatient Infectious Diseases consultation requests increased dramatically throughout both COVID periods, the corresponding drop in our travel and outpatient patient volumes created the effect of only minimal revenue increases, if any, despite the added time efforts noted by our providers (S1, S2). This loss in practice revenue owing to loss of Travel Clinic volumes had not yet recovered to the pre-pandemic levels by the end of Late COVID. The drop in pre-travel consultation numbers and revenue seen in our clinic were also seen in other travel clinics in the US and in other countries. An International Society of Travel Medicine (ISTM) survey performed in April and May of 2021, revealed that 70% of respondents reported substantial reductions in travel clinic volumes. 15 A report on the impact in Southern Europe showed an overall drop of 75–90% for pre-travel assessments. 16 Such reductions in travel clinic volumes could have a devastating impact on free-standing travel clinics or sites that cannot easily shift personnel and resources elsewhere. 17 This could result in a reduction in public health benefits that travel medicine services can provide. Also impacting the revenue decline would be the loss in income attributable to fewer vaccinations administered during COVID. Traveler demographics themselves changed significantly, with younger travelers consulting pre-travel services more during the Early-COVID-19 period and overall, the travelers were healthier, when looking at the number of pre-existing medical conditions and the number of current medications. Interestingly, most of these demographic features were recalibrating back toward baseline during the Late-COVID-19 period, particularly a much higher proportion of senior travelers and corresponding shorter trip durations. VFR travel proportionally rose dramatically during Early COVID-19, while travel for leisure and business decreased significantly. In addition to an increase in VFR travel, we also noted a significant surge in the proportion of travelers leaving for humanitarian work. Most of the changes in reason for travel seem to re-calibrate quickly in the Late COVID period. We also found a significant increase in proportional travel to Africa, especially by VFR travelers, and especially for longer durations. This may reflect individuals traveling back to countries of origin during pandemic, perhaps either for family or financial reasons. The proportional increase of travelers to Africa may in part reflect the desire or need to obtain yellow fever vaccination to assist country entry. VFR travel has been a main driver in more recent returns to higher international travel volume with some forecasts suggesting a 17% compounded annual growth rate from 2021 − 25. 18 This trend is likely to continue. Along with the improved health of travelers noted in the Early COVID-19 period, there were fewer vaccines given to patients during this period and throughout the Late COVID-19 period. It was not clear if the reduction in vaccines administered during Early/Late COVID-19, reflected increased declination or provider assessment of vaccine need. Perhaps some of the reduction in vaccination we saw during Early COVID-19 may have been in part due to a significant increase in the proportion of self-pay travelers (not insured) who may have opted to forgo some of the recommended immunizations due to cost concerns. Alternatively, considering the corresponding increase in VFR travel, fewer vaccines were ordered. It is well documented that VFR travelers are often under-vaccinated for similar destinations as other travelers and more often may decline recommended vaccinations. 19 Certain vaccinations did show high acceptance rates during the Early COVID-19, including Yellow Fever, hepatitis A, and typhoid vaccines. Consistent with other data, travel durations were longer with more travelers going for over 4 weeks. The destinations changed significantly as well with more trips to the African continent and correspondingly fewer trips to South America and Southeast Asia. We believe that destination changes were a result of global travel restrictions as well as destinations to which VFR travelers returned. 18 , 19 , 20 It is possible that many VFR travelers decided to isolate themselves and work remotely for their jobs, from their countries of origin and to be with family members, in association, perhaps with a lower cost of living. The changes in our traveler demographics were similar to a prior analysis of the larger GTEN database, reviewing over 18,000 consultations which showed significant differences among international travelers during COVID-19, with longer durations of travel, an increase in proportions of younger travelers and an increase in VFR travel. 6 Travel to Africa increased significantly in this larger study, with a reduction in travel to Asia, similar to our findings. That review included a large pediatric population, showing a 263% relative increase through the COVID-19 period. It is likely that this was a consistent theme across the US, particularly during early COVID-19. We believe our data is helpful for future planning for pandemics or during global travel restrictions. Our 85% drop in travel-revenue through Early COVID-19 was substantial and can add to the stress of an already overburdened Infectious Diseases or other medical practice. Practices that rely heavily on Travel Medicine as part of their revenue stream will need to consider having remediation plans in place to weather future restrictions should they occur. Furthermore, addressing the particular needs of younger, particularly VFR travelers, would be important going forward, realizing that many do not seek pre-travel consultation and may be at higher risk for preventable adverse outcomes including, malaria typhoid fever, and hepatitis. 21 There are a few limitations to our analysis: Data collected by the GTEN are limited to travelers who seek pre-travel advice from a GTEN site and hence these results cannot be generalized to a broader pre-travel population, many of whom might not seek pre-travel consultation and have been shown to differ from GTEN travelers. 9 Second, in the GTEN, the travelers self-report their medical conditions, medications, and reason for travel. This can be corrected at the pre-travel visit by the provider onsite, but there is the potential for travelers to omit or overstate the number of potential health problems as compared with a detailed provider history. As such, the traveler’s overall health cannot always be accurately gauged by the results of the pre-travel survey. Lastly, this study was from a single site within a specific type of healthcare network. Our findings may not be generalizable to other travel clinics or to the healthcare networks that support them. Conclusions This study shows that the financial impact of COVID-19 on an academic-based, medium-sized travel medicine clinic was substantial. Major revenue loss was sustained over three years. Such losses could be devastating to stand-alone travel medicine clinics. Travelers during Early COVID-19 were younger, healthier, traveled to Africa, traveled for longer periods of time, and received fewer vaccinations as compared with the Pre-COVID-19 period. Enhanced education and messaging on ways to mitigate illness may be indicated for such travelers in the future. Recovery began in Late COVID-19 but has not yet returned to Pre-COVID levels. Declarations Conflict of Interest PP-no conflict Funding: The Global TravEpiNet is supported by the US Centers for Disease Control and Prevention (U01-CK000633). Author Contribution MK and MG: creation of original concept and protocol. SR provided access to the GTEN database. SR did the data searches and provided statistical analysis. PP, MK, MG and SR did the initial manuscript writing and revisions. All authors contributed to formal review and approval of this manuscript. Acknowledgement The authors graciously acknowledge the detailed review and suggestions from Dr. Regina C. LaRocque, MD, MPH and Dr. Edward T. Ryan, MD in preparing this manuscript and granting GTEN access. We also would like to thank Jennifer O. Eddinger, MBA, MS, for her valuable assistance in supplying the financial data from TruSource and documenting the accuracy of the revenue data in this study. Additionally, we are grateful for the statistical analysis performed by Hope Kincaid, MPH, CPH on the clinic revenue and insurance changes over time. Data availability The full datasets analyzed during the current study are available from the corresponding author on request. References CDC. CDC Museum COVID-19 Timeline : 10 July 2023. https//www.cdc.gov/museum/timeline/covid19.html Bauer IL. COVID-19: how can travel medicine benefit from tourism’s focus on people during a pandemic? Trop Dis Trav Med Vaccines. 2022;8:1–14. Leong WY. COVID-19’s impact in travel medicine surpasses that of all other emerging viral diseases. Editorial. J Travel Med. 2020;22:1–2. International Civil Aviation Organization. 27, April. 2023. Effects of Novel Coronavirus (COVID-19) on Civil Aviation Economic Impact Analysis . Montreal, Canada. Accessed August 17, 2023. https://www.icao.int/sustainability/Documents/Covid-19/ICAO_coronavirus_Econ_Impact.pdf Hatz C, Chen LH. Pretravel Consultation. In: Keystone JS, Kozarsky PE, Connor BA, et al. editors. Travel Medicine. Fourth Edition. Edinburgh: Elsevier; 2019. pp. 25–30. Hyle EP, Le MH, Rao SR et al. August. High-risk International Travelers Seeking Pretravel Consultation During the COVID-19 Pandemic. Open Forum ID online 3 2022. https://doi.org/10.1093/ofid/ofac399 Consumer Insights and Analytics. - Lehigh Valley Health Network data analytics. Claritas Epic: September 21, 2023. CTH: Certificate in Travel Health, International Society of Travel Medicine., The International Society of Travel Medicine (istm.org) https://www.istm.org/content.asp?contentid=34 . Accessed October 3, 2023. Global TravEpiNet. 2023, Global TravEpiNet is a nationwide consortium of travel clinics that is focused on improving disease prevention and performing research in international travelers. Boston, Massachusetts, USA. Accessed December 4, 2023. https://gten.massgeneral.org LaRocque RC, Rao SR, Lee J, et al. Global TravEpiNet: A National Consortium of Clinics Providing Care to International Travelers–Analysis of Demographic Characteristics, Travel Destinations, and Pretravel Healthcare of High-Risk US International Travelers, 2009–2011. Clin Infect Dis. 2012;54:455–62. WHO. Countries/areas by WHO region. Countries and areas by WHO region – 12bfe12.pdf. Accessed July 8, 2023. Adjei S, Hong K, Molinari NM et al. Mortality Risk Among Patients Hospitalized Primarily for COVID-19 During the Omicron and Delta Variant Pandemic Periods - United States, April 2020-June 2022. MMWR 2022; 71:1182-89. IBI. iBiTM WebFOCUS - Harness the power of data to drive informed decision-making across your organization and for your customers . Accessed October 19, 2023. Wanduragala D, Coyle C, Angelo K. and Stauffer. Visiting Friends & Relatives: VFR Travel. In: Nemhauser, JB ed. CDC Yellow Book. Oxford University Press 2024. VFR is defined as a person who currently resides in a higher-income country who returns to their former home (in a lower-income country) for the purpose of visiting friends and/or relatives. Acosta RW, Visser JT, Chen LH, et al. Adaptation of travel medicine practitioners to the COVID-19 pandemic: a cross-sectional survey of ISTM members. J Travel Med. 2022;29:1–3. Gobbi F, Noharet R, Abreu C, et al. South Europe perspective of COVID-19 impact on Travel Medicine. J Travel Med. 2021;28:1–3. Chiodi J. COVID-19 and the impact on travel health advice. Trav Med Infect Dis. 2020 July-Aug;36:101824. https://doi.org/10.1016/j.tmaid.2020.101824 . Published online 2020 Jul 23. Bonhill-Smith J. Visiting friends and relatives will be a driving force behind travel’s recovery https://www.globaldata.com/media/travel-tourism/visiting-friends-relatives-will-driving-force-behind-travels-recovery/ . Accessed September 29, 2023. LaRocque RC, Deshpande BR, Rao SR, et al. Pre-Travel Health Care of Immigrants Returning Home to Visit Friends and Relatives. Am J Trop Med Hyg. 2013;88:376–80. Ferrara P, Masuet-Aumatell C, Ramon-Torrell J. Pre-travel health care attendance among migrant travellers visiting friends and relatives (VFR): a 10-year retrospective analysis. BMC Public Health 2019; 1397–404. Behrens RH, Leder K. Visiting Friends and Relatives. In: Keystone JS, Kozarsky PE, Connor BA, et al. editors. Travel Medicine. Fourth Edition. Edinburgh: Elsevier; 2019. pp. 312–14. Additional Declarations No competing interests reported. Supplementary Files SupplementaryDataPalwaietal.April172024.docx Supplement4jpegversion.jpg Supplement5jpegversion.jpg Supplement6jpegversion.jpg Cite Share Download PDF Status: Published Journal Publication published 01 Mar, 2025 Read the published version in Tropical Diseases, Travel Medicine and Vaccines → Version 1 posted Editorial decision: Revision requested 18 Oct, 2024 Reviews received at journal 15 Oct, 2024 Reviewers agreed at journal 11 Oct, 2024 Reviews received at journal 22 Aug, 2024 Reviewers agreed at journal 15 Aug, 2024 Reviewers agreed at journal 13 Aug, 2024 Reviewers invited by journal 13 Aug, 2024 Editor assigned by journal 08 Aug, 2024 Submission checks completed at journal 08 Aug, 2024 First submitted to journal 30 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Rao","email":"","orcid":"","institution":"Boston University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Sowmya","middleName":"R.","lastName":"Rao","suffix":""},{"id":344368456,"identity":"42054f07-e8ab-4410-94c3-fba3ab26fb29","order_by":3,"name":"Mark C. Knouse","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYLACxgYQyXzwAZDk4SNBC1uyAUgLGwlaeMwkwDoJqTZn7zH+8HGHTeL89gazyq85djJsDMwPH93Ao8Wy54yZ5MwzaYkbzhxIuy27LRnoMDZj4xw8Wgxu5Jgx87YdTtwgkXDstuQ2ZqAWHjZpAlqMP/8Fapk//2FbseS2eqK0GEgzArU03GBmY/y47TARWs4cK5PsbUsz3nAmjVmacdtxHjZmQn453rz5w882G9n57ec/fvy5rdqen7354WN8WlAAMw+YJFY5CDD+IEX1KBgFo2AUjBgAAMQHSiv63LG7AAAAAElFTkSuQmCC","orcid":"","institution":"Lehigh Valley Health Network","correspondingAuthor":true,"prefix":"","firstName":"Mark","middleName":"C.","lastName":"Knouse","suffix":""}],"badges":[],"createdAt":"2024-07-30 16:20:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4830164/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4830164/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40794-024-00239-8","type":"published","date":"2025-03-01T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64623366,"identity":"4b8a0083-f4fc-4884-af03-d534722cdfbf","added_by":"auto","created_at":"2024-09-16 16:59:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":211188,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eQuarterly trends of traveler visit volume and revenue generated by the travel clinic across three periods\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/1b3597fd5eeb94e38e10979c.jpg"},{"id":64622583,"identity":"3d2fb44c-5049-478e-888f-22ef5cca35bb","added_by":"auto","created_at":"2024-09-16 16:51:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":635906,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTravel destinations during the Pre, Early and Late COVID-19 periods.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"PreCOVIDdestinationsFigure2a.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/af93e703fd238279d0c78a90.jpg"},{"id":64623365,"identity":"7b30e0ed-961a-48dc-9b12-048cb0f1c570","added_by":"auto","created_at":"2024-09-16 16:59:49","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":117373,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eReason for Travel Change Over Time\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/40e4c9b0af6fef85ecf92b93.jpg"},{"id":64623367,"identity":"24d7ed79-5ae6-4c6c-9c25-d6659bb53d85","added_by":"auto","created_at":"2024-09-16 16:59:49","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":131564,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentage of Travelers Who Received Vaccinations\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/04f88c17b0d25b2d5728ffcc.jpg"},{"id":77622534,"identity":"d3867ff7-0e60-4110-be50-76c043e6c7d8","added_by":"auto","created_at":"2025-03-03 16:08:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1858672,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/b626336c-a2f8-4172-886f-6c713a1dc8c7.pdf"},{"id":64623364,"identity":"eeef7377-16a1-4565-a239-9909322cfbb5","added_by":"auto","created_at":"2024-09-16 16:59:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":38608,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryDataPalwaietal.April172024.docx","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/acc6e9fb18dac48f794c25d1.docx"},{"id":64622587,"identity":"dab2134f-cda9-4308-a99c-6000852f4f59","added_by":"auto","created_at":"2024-09-16 16:51:49","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":143807,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement4jpegversion.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/2d7d7542fe304c6e4335d0fb.jpg"},{"id":64622585,"identity":"22d151e6-ade7-43aa-921a-184b5ec7c1e8","added_by":"auto","created_at":"2024-09-16 16:51:49","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":182568,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement5jpegversion.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/a62981583a07640ce10f814f.jpg"},{"id":64622588,"identity":"1bbf06a1-f7fb-4186-9b54-688bebc8b98f","added_by":"auto","created_at":"2024-09-16 16:51:49","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":111398,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement6jpegversion.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4830164/v1/c70d24395e1e3b709550e6b2.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of COVID-19 on a Medium-Sized Travel Medicine Clinic in Eastern Pennsylvania, USA","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn early 2020, COVID-19, also known as Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), disrupted international travel for a variety of reasons. Governmental regulations contributed to this, and on March 19, 2020, the US instituted a Global Level 4 Health Advisory of \u0026ldquo;Do not travel\u0026rdquo; in an attempt to contain the pandemic and prevent its spread.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The degree of risk perception during pandemics varies among individuals, which may affect the decision to travel, destinations for travel, as well as the duration of international trips.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe impact of the pandemic on international travel and the travel-related industry was enormous.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e For example, The International Civil Aviation Organization (ICAO) reported in April 2023 a 60% drop in total world passengers in 2020 compared with the 2019 baseline, and a 49% overall drop for the year 2021 compared to 2019. The corresponding revenue loss to the airline industry during calendar year 2020 as compared to 2019 was estimated at 372\u0026nbsp;billion in USD.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrior to international travel, individuals may seek care and advice at a travel medicine clinic in order to mitigate health and safety risks at their destinations. These consultations typically include advice and education, vaccination, and the prescribing of chemoprophylaxis such as to prevent malaria.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs a medium-sized travel clinic in the eastern part of Pennsylvania, we sought to assess the impact of the pandemic on our travel clinic from multiple perspectives, including changes in the traveler demographics and the travel profile as well as the financial impact to the clinic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eOur travel clinic in Eastern Pennsylvania is located in the Lehigh Valley, serving the Valley population and some contiguous communities as the primary catchment base. This catchment base includes 910,000 local residents.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The travel clinic is embedded in a larger Infectious Diseases practice as a part of a large tertiary-care health network of 13 hospitals of various sizes that include many specialty residency training programs. Staffing the travel clinic are ten board-certified Infectious Diseases physicians and two Physician Assistants, the majority of whom have a Certification of Travel Health.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e During the two years preceding the COVID-19 pandemic, our travel clinic generated approximately 3.7% of all of the Infectious Disease practice revenue (counting outpatient and inpatient consultations).\u003c/p\u003e \u003cp\u003ePrior to the onset of COVID-19 our travel clinic performed on average 1,353 pre-travel visits/year. We submit our pre-travel data to the Global TravEpiNet (GTEN network), which is a de-identified national registry and database of travelers coordinated by Massachusetts General Hospital and supported by the U.S. Centers for Disease Control and Prevention (CDC).\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e GTEN data include variables such as traveler demographics, medical history, medications, travel itinerary, duration and purpose of travel, and vaccination information.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Clinicians offering these consultations verify this information, add detailed immunization history, input vaccines administered, enter prescribed medications and document specific counseling provided.\u003c/p\u003e \u003cp\u003eTravelers who seek pre-travel counseling at our clinic are asked to pay the full consultation fee by cash or credit card at the time of the visit. The payment for any recommended vaccination is dependent on the traveler\u0026rsquo;s insurance coverage. Our clinic accepts all insurance types present in our region: HMO, PPO, Medicare, State funded plans (Medicaid), Veterans\u0026rsquo; Administration, and private insurances. Patients without insurance coverage (self-pay) are expected to cover the costs of the vaccines themselves. Many insurances will cover certain vaccines, typically those in routine US Advisory Committee of Immunization Practice (ACIP) guidelines, for example measles-mumps-rubella (MMR), tetanus-diphtheria and acellular pertussis (Tdap), inactivated polio, and hepatitis A. However, many insurance plans do not include coverage for other vaccines including typhoid, yellow fever, rabies, Japanese Encephalitis, or cholera vaccines. For these latter vaccines, patients are expected to pay cash/credit card at the time of service. Many Medicare, state Medicaid, and HMO plans require that travelers receive some of their routine vaccines (e.g. hepatitis A, Tdap) at either their primary care provider, or at a retail pharmacy.\u003c/p\u003e \u003cp\u003eFor this study, we considered only data pertaining to adult (\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;18 years) travelers visiting our clinic between January 2018 through March 2023. We assessed changes in traveler demographics, destinations (by WHO region and by country)\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, duration and reasons for travel, and overall health during the three periods defined as Pre-COVID-19 (January 2018-December 2019), Early COVID-19 (April 2020-March 2022) and Late COVID-19 (April 2022-March 2023). We created a variable to indicate reasons of travel with mutually exclusive categories: leisure, humanitarian service work, business, research and education, visiting family and relatives in a country of origin (VFR) and other reasons (e.g., adoption, military service, adventure, gatherings) indicating a hierarchy. For example, if someone traveled for leisure and any other purpose of travel, they were categorized as having traveled for leisure. We used data on the number of medical conditions and the number of medications taken to characterize the overall health of the traveler. The number of vaccines given per patient were tabulated for each of the three time periods.\u003c/p\u003e \u003cp\u003eThe first confirmed case of COVID-19 seen in our network was in March of 2020. We censored January through March of 2020 as the pandemic had not yet arrived in our region. April 1, 2022 was set as the beginning of the Late COVID-19 period as this was the time when a second Omicron wave crossed much of the United States and overall COVID-19-related mortality began to decrease\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. These same parameters were used to analyze the financial impact the clinic faced in terms of visit volumes and revenue during this period. To assess the impact on revenue, we reviewed data stored in our network\u0026rsquo;s financial database, TruSource (WebFOCUS).\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e This data was then compared with trends in the demographic data from travel consultations.\u003c/p\u003e \u003cp\u003eThis study was deemed non-human subject research by the Institutional Review Board at Lehigh Valley Health Network.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eSummary statistics (e.g., proportions) were obtained and bivariate analyses using a two-sided chi-square test were conducted to assess the significance of the difference in the distributions of the variables across the three time periods. All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC) and a two-sided p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003cp\u003eThe revenue data were normally distributed as assessed by the Shapiro-Wilk test (p values of 0.63, 0.36, and 0.98 for Pre-, Early and Late COVID respectively). There was homogeneity of variances as assessed by Levene\u0026rsquo;s test for equality of variances (p\u0026thinsp;=\u0026thinsp;0.4856). An omnibus one-way ANOVA was conducted to determine if quarterly revenue differed significantly across the three COVID periods defined as \u0026ndash; Pre-COVID-19 (2018 and 2019, n\u0026thinsp;=\u0026thinsp;8), Early COVID-19 (April 2020-March 2022, n\u0026thinsp;=\u0026thinsp;8), and Late COVID-19 (April 2022-March 2023, n\u0026thinsp;=\u0026thinsp;4). Tukey post hoc analysis was conducted to determine specifically in which quarters revenue differed significantly.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEarly COVID Period\u003c/h2\u003e \u003cp\u003eWe reviewed 3,510 travel records. 2,663 from the 24 month Pre-COVID-19 period, 429 from the 24 month Early COVID-19 and 418 from the 12 month Late COVID-19 periods (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We observed an 84% decrease in travel clinic volume between the Pre-COVID-19 and Early COVID-19 periods (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There was a proportional decrease in travelers over age 65 years seen at the clinic (11%) in Early COVID-19 compared with Pre-COVID-19 (16%). The duration of travel increased during the Early COVID-19 period compared with Pre-COVID-19. 62% of travelers seen during Early COVID-19 were traveling for 14 days or longer, compared with 49% Pre-COVID-19. 18.5% of travelers seen during Early COVID-19 were traveling for 28 days or longer, compared with 12% Pre-COVID-19. The most striking proportional change in destination was to Africa, with 77.2% of all travelers seen during early COVID-19 traveling to Africa, versus 47.6% pre-COVID-19 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). We saw a 10.5% absolute increase (300% proportional increase) in VFR travel\u003csup\u003e14\u003c/sup\u003e and 3.5% absolute increase (17.5% proportional increase) in humanitarian service work (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) during the Early COVID-19 period with a corresponding absolute 6.4% drop in leisure and 6.6% drop in business travel (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTraveler\u0026rsquo;s Demographics, Destinations, and Duration of Travel Across the Three Periods of COVID-19\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2663(75.9%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEarly Post-\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;429 (12.2%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLate Post-\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;418 (11.9%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;3510\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (\u003c/b\u003ep\u0026thinsp;=\u0026thinsp;0.773)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1159 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e194 (45.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e186 (44.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1504 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e235 (54.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e232 (55.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1447 (54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e255 (59.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e201 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e789 (29.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e127 (29.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e118 (28.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e427 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (11.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99 (23.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of Travel\u003c/b\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;14 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1354 (50.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e162 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e192 (45.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u0026ndash;28 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e989 (37.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e186 (43.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e177 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;28 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e320 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion of Travel\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrica (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1267 (47.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e331 (77.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200 (47.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmericas (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e913 (34.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e110 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoutheast Asia (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern Pacific (p\u0026thinsp;=\u0026thinsp;0.0006)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e271 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEastern Mediterranean (p\u0026thinsp;=\u0026thinsp;0.2234)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEurope (p\u0026thinsp;=\u0026thinsp;0.1766)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReason for Travel\u003c/b\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeisure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1317 (49.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e185 (43.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e239 (57.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHumanitarian Service Work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e533 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (15.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e368 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch/Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e291 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (8.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVFR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Pre-existing Medical Conditions\u003c/b\u003e (p\u0026thinsp;=\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e641 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69 (16.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e720 (27.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94 (22.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e592 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98 (22.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113 (27.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e710 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96 (22.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142 (34.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Current Medications Taken\u003c/b\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e816 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e162 (37.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111 (26.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e617 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (20.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (16.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e419 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62 (14.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e811 (30.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118 (27.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e177 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of Vaccinations received\u003c/b\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e174 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63 (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87 (20.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e916 (34.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e136 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e832 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124 (29.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e741 (27.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102 (23.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eSupplementary data\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSupplementary data are available at Tropical Diseases, Travel Medicine, and Vaccines online.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRegarding traveler health, during the Early COVID-19, there was a 4.2% decrease in the number of travelers with 2 or more medical conditions (proportional 16% decrease) and a 4.3% absolute increase in number of travelers taking none or only one medication (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Vaccinations received per traveler during Early COVID-19 decreased from Pre-COVID-19; with 8.2% more travelers receiving zero vaccines and a 4% decline (proportional 14% decline) in travelers receiving 2 or more vaccines (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn terms of volume and revenue, COVID-19 resulted in an 84% drop (from an average 338 visits per quarter to 52 visits per quarter) in travel patient volumes, and a corresponding 85% proportional revenue drop for the travel clinic per quarter in the Early COVID-19 period from the Pre-COVID-19 period (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, S1). The travel clinic\u0026rsquo;s share of revenue in the Infectious Diseases practice dropped to \u0026lt;\u0026thinsp;1% during the COVID-19 pandemic and had not recovered to the Pre-COVID-19 levels by March 2023. By March 2023, quarterly clinic revenue [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation] was still at only 28% of Pre-COVID-19 values, (Pre-COVID-19 [\u003cspan\u003e$\u003c/span\u003e32,630.00\u0026plusmn;\u003cspan\u003e$\u003c/span\u003e4,356.58]; Early COVID-19 period [\u003cspan\u003e$\u003c/span\u003e5,014.38\u0026plusmn;\u003cspan\u003e$\u003c/span\u003e2,796.09]; Late-COVID-19 period [\u003cspan\u003e$\u003c/span\u003e9,044.00\u0026plusmn;\u003cspan\u003e$\u003c/span\u003e3,217.58] (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAll individuals in this assessment paid for their pre-travel consultation aspect of the bill at the time of service throughout the three periods. Review of the traveler\u0026rsquo;s insurance coverage for vaccinations showed that there was a significant increase in self-pay (uninsured) individuals from the Pre- to Early COVID-19 periods (20.6% and 32.2% respectively) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while those with commercial insurance showed a significant decrease from Pre- to Early COVID-19 (55.5% and 45.4% respectively) (S3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eLate-COVID-19 Period\u003c/h2\u003e \u003cp\u003eDuring the Late COVID-19 period, there was an increase in travelers over 65 years of age (24%) versus Early COVID-19 (11%) and Pre-COVID (16%), and a reduction in trips longer than 28 days (11.7%) versus early COVID-19 (18.5%) and Pre-COVID-19 (12%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Travel to Africa as a proportion of clinic visits also fell appreciably (47.8%) versus early COVID-19 (77.2%) returning to Pre-COVID-19 proportion (47.6%). Using fewer medical conditions and fewer medications as a surrogate for healthier travelers, we saw generally healthier travelers in the Early COVID-19 period as compared to the Pre-COVID-19 period (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and S4, S5, S6). Vaccination uptake also changed significantly as there was an increase in the proportion of travelers who took no vaccinations from the Pre-COVID-19 period through the Late-COVID-19 period (6.5\u0026ndash;20.8%) continuing on an upwards trend, while the proportion of individuals taking over 3 vaccines dropped significantly across the three periods from 27.8\u0026ndash;17% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDuring both COVID-19 time periods, inpatient Infectious Diseases consultation requests increased dramatically (absolute increase of 57.4% from calendar year 2019 to 2020 and 7.9% from 2020 to 2021).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur retrospective record review revealed that the COVID-19 pandemic resulted in a large drop in travel clinic volumes and associated revenue from the Pre-COVID period and that these decreases were still present in the Late COVID-19 period although increases were occurring. This corresponds to the large decrease in international travel numbers due to travel restrictions and concerns about contracting COVID. Although our volume of inpatient Infectious Diseases consultation requests increased dramatically throughout both COVID periods, the corresponding drop in our travel and outpatient patient volumes created the effect of only minimal revenue increases, if any, despite the added time efforts noted by our providers (S1, S2). This loss in practice revenue owing to loss of Travel Clinic volumes had not yet recovered to the pre-pandemic levels by the end of Late COVID.\u003c/p\u003e \u003cp\u003eThe drop in pre-travel consultation numbers and revenue seen in our clinic were also seen in other travel clinics in the US and in other countries. An International Society of Travel Medicine (ISTM) survey performed in April and May of 2021, revealed that 70% of respondents reported substantial reductions in travel clinic volumes.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e A report on the impact in Southern Europe showed an overall drop of 75\u0026ndash;90% for pre-travel assessments.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Such reductions in travel clinic volumes could have a devastating impact on free-standing travel clinics or sites that cannot easily shift personnel and resources elsewhere.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This could result in a reduction in public health benefits that travel medicine services can provide. Also impacting the revenue decline would be the loss in income attributable to fewer vaccinations administered during COVID.\u003c/p\u003e \u003cp\u003eTraveler demographics themselves changed significantly, with younger travelers consulting pre-travel services more during the Early-COVID-19 period and overall, the travelers were healthier, when looking at the number of pre-existing medical conditions and the number of current medications. Interestingly, most of these demographic features were recalibrating back toward baseline during the Late-COVID-19 period, particularly a much higher proportion of senior travelers and corresponding shorter trip durations.\u003c/p\u003e \u003cp\u003eVFR travel proportionally rose dramatically during Early COVID-19, while travel for leisure and business decreased significantly. In addition to an increase in VFR travel, we also noted a significant surge in the proportion of travelers leaving for humanitarian work. Most of the changes in reason for travel seem to re-calibrate quickly in the Late COVID period.\u003c/p\u003e \u003cp\u003eWe also found a significant increase in proportional travel to Africa, especially by VFR travelers, and especially for longer durations. This may reflect individuals traveling back to countries of origin during pandemic, perhaps either for family or financial reasons. The proportional increase of travelers to Africa may in part reflect the desire or need to obtain yellow fever vaccination to assist country entry. VFR travel has been a main driver in more recent returns to higher international travel volume with some forecasts suggesting a 17% compounded annual growth rate from 2021\u0026thinsp;\u0026minus;\u0026thinsp;25.\u003csup\u003e18\u003c/sup\u003e This trend is likely to continue.\u003c/p\u003e \u003cp\u003eAlong with the improved health of travelers noted in the Early COVID-19 period, there were fewer vaccines given to patients during this period and throughout the Late COVID-19 period. It was not clear if the reduction in vaccines administered during Early/Late COVID-19, reflected increased declination or provider assessment of vaccine need. Perhaps some of the reduction in vaccination we saw during Early COVID-19 may have been in part due to a significant increase in the proportion of self-pay travelers (not insured) who may have opted to forgo some of the recommended immunizations due to cost concerns. Alternatively, considering the corresponding increase in VFR travel, fewer vaccines were ordered. It is well documented that VFR travelers are often under-vaccinated for similar destinations as other travelers and more often may decline recommended vaccinations.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Certain vaccinations did show high acceptance rates during the Early COVID-19, including Yellow Fever, hepatitis A, and typhoid vaccines.\u003c/p\u003e \u003cp\u003eConsistent with other data, travel durations were longer with more travelers going for over 4 weeks. The destinations changed significantly as well with more trips to the African continent and correspondingly fewer trips to South America and Southeast Asia. We believe that destination changes were a result of global travel restrictions as well as destinations to which VFR travelers returned.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e It is possible that many VFR travelers decided to isolate themselves and work remotely for their jobs, from their countries of origin and to be with family members, in association, perhaps with a lower cost of living.\u003c/p\u003e \u003cp\u003eThe changes in our traveler demographics were similar to a prior analysis of the larger GTEN database, reviewing over 18,000 consultations which showed significant differences among international travelers during COVID-19, with longer durations of travel, an increase in proportions of younger travelers and an increase in VFR travel.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Travel to Africa increased significantly in this larger study, with a reduction in travel to Asia, similar to our findings. That review included a large pediatric population, showing a 263% relative increase through the COVID-19 period. It is likely that this was a consistent theme across the US, particularly during early COVID-19.\u003c/p\u003e \u003cp\u003eWe believe our data is helpful for future planning for pandemics or during global travel restrictions. Our 85% drop in travel-revenue through Early COVID-19 was substantial and can add to the stress of an already overburdened Infectious Diseases or other medical practice. Practices that rely heavily on Travel Medicine as part of their revenue stream will need to consider having remediation plans in place to weather future restrictions should they occur. Furthermore, addressing the particular needs of younger, particularly VFR travelers, would be important going forward, realizing that many do not seek pre-travel consultation and may be at higher risk for preventable adverse outcomes including, malaria typhoid fever, and hepatitis.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are a few limitations to our analysis:\u003c/p\u003e \u003cp\u003eData collected by the GTEN are limited to travelers who seek pre-travel advice from a GTEN site and hence these results cannot be generalized to a broader pre-travel population, many of whom might not seek pre-travel consultation and have been shown to differ from GTEN travelers.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSecond, in the GTEN, the travelers self-report their medical conditions, medications, and reason for travel. This can be corrected at the pre-travel visit by the provider onsite, but there is the potential for travelers to omit or overstate the number of potential health problems as compared with a detailed provider history. As such, the traveler\u0026rsquo;s overall health cannot always be accurately gauged by the results of the pre-travel survey.\u003c/p\u003e \u003cp\u003eLastly, this study was from a single site within a specific type of healthcare network. Our findings may not be generalizable to other travel clinics or to the healthcare networks that support them.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study shows that the financial impact of COVID-19 on an academic-based, medium-sized travel medicine clinic was substantial. Major revenue loss was sustained over three years. Such losses could be devastating to stand-alone travel medicine clinics. Travelers during Early COVID-19 were younger, healthier, traveled to Africa, traveled for longer periods of time, and received fewer vaccinations as compared with the Pre-COVID-19 period. Enhanced education and messaging on ways to mitigate illness may be indicated for such travelers in the future. Recovery began in Late COVID-19 but has not yet returned to Pre-COVID levels.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003ePP-no conflict\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe Global TravEpiNet is supported by the US Centers for Disease Control and Prevention (U01-CK000633).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMK and MG: creation of original concept and protocol. SR provided access to the GTEN database. SR did the data searches and provided statistical analysis. PP, MK, MG and SR did the initial manuscript writing and revisions. All authors contributed to formal review and approval of this manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors graciously acknowledge the detailed review and suggestions from Dr. Regina C. LaRocque, MD, MPH and Dr. Edward T. Ryan, MD in preparing this manuscript and granting GTEN access. We also would like to thank Jennifer O. Eddinger, MBA, MS, for her valuable assistance in supplying the financial data from TruSource and documenting the accuracy of the revenue data in this study. Additionally, we are grateful for the statistical analysis performed by Hope Kincaid, MPH, CPH on the clinic revenue and insurance changes over time.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eThe full datasets analyzed during the current study are available from the corresponding author on request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCDC. \u003cem\u003eCDC Museum COVID-19 Timeline\u003c/em\u003e: 10 July 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps//www.cdc.gov/museum/timeline/covid19.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/museum/timeline/covid19.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauer IL. COVID-19: how can travel medicine benefit from tourism\u0026rsquo;s focus on people during a pandemic? Trop Dis Trav Med Vaccines. 2022;8:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeong WY. COVID-19\u0026rsquo;s impact in travel medicine surpasses that of all other emerging viral diseases. Editorial. J Travel Med. 2020;22:1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Civil Aviation Organization. 27, April. 2023. \u003cem\u003eEffects of Novel Coronavirus (COVID-19) on Civil Aviation Economic Impact Analysis\u003c/em\u003e. Montreal, Canada. Accessed August 17, 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.icao.int/sustainability/Documents/Covid-19/ICAO_coronavirus_Econ_Impact.pdf\u003c/span\u003e\u003cspan address=\"https://www.icao.int/sustainability/Documents/Covid-19/ICAO_coronavirus_Econ_Impact.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatz C, Chen LH. Pretravel Consultation. In: Keystone JS, Kozarsky PE, Connor BA, et al. editors. Travel Medicine. Fourth Edition. Edinburgh: Elsevier; 2019. pp. 25\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHyle EP, Le MH, Rao SR et al. August. High-risk International Travelers Seeking Pretravel Consultation During the COVID-19 Pandemic. \u003cem\u003eOpen Forum ID\u003c/em\u003e online 3 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ofid/ofac399\u003c/span\u003e\u003cspan address=\"10.1093/ofid/ofac399\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConsumer Insights and Analytics. - Lehigh Valley Health Network data analytics. Claritas Epic: September 21, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCTH: Certificate in Travel Health, International Society of Travel Medicine., The International Society of Travel Medicine (istm.org)\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.istm.org/content.asp?contentid=34\u003c/span\u003e\u003cspan address=\"https://www.istm.org/content.asp?contentid=34\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed October 3, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal TravEpiNet. 2023, \u003cem\u003eGlobal TravEpiNet is a nationwide consortium of travel clinics that is focused on improving disease prevention and performing research in international travelers.\u003c/em\u003e Boston, Massachusetts, USA. Accessed December 4, 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gten.massgeneral.org\u003c/span\u003e\u003cspan address=\"https://gten.massgeneral.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaRocque RC, Rao SR, Lee J, et al. Global TravEpiNet: A National Consortium of Clinics Providing Care to International Travelers\u0026ndash;Analysis of Demographic Characteristics, Travel Destinations, and Pretravel Healthcare of High-Risk US International Travelers, 2009\u0026ndash;2011. Clin Infect Dis. 2012;54:455\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Countries/areas by WHO region. Countries and areas by WHO region \u0026ndash;\u0026thinsp;12bfe12.pdf. Accessed July 8, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdjei S, Hong K, Molinari NM et al. Mortality Risk Among Patients Hospitalized Primarily for COVID-19 During the Omicron and Delta Variant Pandemic Periods - United States, April 2020-June 2022. \u003cem\u003eMMWR\u003c/em\u003e 2022; 71:1182-89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIBI. \u003cem\u003eiBiTM WebFOCUS - Harness the power of data to drive informed decision-making across your organization and for your customers\u003c/em\u003e. Accessed October 19, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWanduragala D, Coyle C, Angelo K. and Stauffer. Visiting Friends \u0026amp; Relatives: VFR Travel. In: Nemhauser, JB ed. CDC Yellow Book. Oxford University Press 2024. VFR is defined as a person who currently resides in a higher-income country who returns to their former home (in a lower-income country) for the purpose of visiting friends and/or relatives.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcosta RW, Visser JT, Chen LH, et al. Adaptation of travel medicine practitioners to the COVID-19 pandemic: a cross-sectional survey of ISTM members. J Travel Med. 2022;29:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGobbi F, Noharet R, Abreu C, et al. South Europe perspective of COVID-19 impact on Travel Medicine. J Travel Med. 2021;28:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiodi J. COVID-19 and the impact on travel health advice. Trav Med Infect Dis. 2020 July-Aug;36:101824. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.tmaid.2020.101824\u003c/span\u003e\u003cspan address=\"10.1016/j.tmaid.2020.101824\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published online 2020 Jul 23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonhill-Smith J. Visiting friends and relatives will be a driving force behind travel\u0026rsquo;s recovery \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.globaldata.com/media/travel-tourism/visiting-friends-relatives-will-driving-force-behind-travels-recovery/\u003c/span\u003e\u003cspan address=\"https://www.globaldata.com/media/travel-tourism/visiting-friends-relatives-will-driving-force-behind-travels-recovery/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed September 29, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaRocque RC, Deshpande BR, Rao SR, et al. Pre-Travel Health Care of Immigrants Returning Home to Visit Friends and Relatives. Am J Trop Med Hyg. 2013;88:376\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrara P, Masuet-Aumatell C, Ramon-Torrell J. Pre-travel health care attendance among migrant travellers visiting friends and relatives (VFR): a 10-year retrospective analysis. BMC Public Health 2019; 1397\u0026ndash;404.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBehrens RH, Leder K. Visiting Friends and Relatives. In: Keystone JS, Kozarsky PE, Connor BA, et al. editors. Travel Medicine. Fourth Edition. Edinburgh: Elsevier; 2019. pp. 312\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"tropical-diseases-travel-medicine-and-vaccines","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tdtm","sideBox":"Learn more about [Tropical Diseases, Travel Medicine and Vaccines](http://tdtmvjournal.biomedcentral.com)","snPcode":"40794","submissionUrl":"https://submission.nature.com/new-submission/40794/3","title":"Tropical Diseases, Travel Medicine and Vaccines","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4830164/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4830164/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic (COVID) disrupted international travel. We sought to determine the impact of the COVID-19 pandemic on patient volume, traveler demographics, and income of our travel clinic in Pennsylvania, USA.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe extracted de-identified pre-travel data on 3,510 pre-travel consultations for adults during: Pre-COVID-19 (January 2018-December 2019), Early COVID-19 (April 2020-March 2022) and Late COVID-19 (April 2022-March 2023). We compared traveler demographics, destinations, purpose of travel, medical conditions, and number of vaccinations administered over time, and we obtained our clinic\u0026rsquo;s revenue from our financial database (TruSource) from the Pre-COVID-19 period to the Early and Late COVID-19 periods.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eWe observed 84% and 85% relative decreases in traveler volume and revenue respectively from the Pre-COVID-19 to the Early COVID-19 period. The proportional decrease in volume was highest for travelers over 65 years of age, decreasing from 16\u0026ndash;11%. Of those that sought care during Early COVID-19, proportionally fewer travelers had multiple co-morbid conditions and were taking chronic medications. Trip length increased and there was a significant proportional increase in travel to Africa. Travel to visit friends or family and for service work also proportionally increased during Early-COVID-19 versus Pre-COVID-19. Clinic volume and revenue began to increase in Late COVID-19 but did not return to Pre-COVID levels.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThe COVID pandemic resulted in a large reduction in patient volume and revenue in our academic-based Pennsylvania travel clinic. We saw substantial changes in our traveler demographics, destinations, as well as reasons and durations of travel.\u003c/p\u003e","manuscriptTitle":"Impact of COVID-19 on a Medium-Sized Travel Medicine Clinic in Eastern Pennsylvania, USA","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 16:51:44","doi":"10.21203/rs.3.rs-4830164/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-18T07:38:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-15T11:02:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262127678303199604550359316206197418138","date":"2024-10-11T10:10:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-22T15:57:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269445628432958772482970742767793947850","date":"2024-08-15T21:21:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147110796920945559873539194344758707714","date":"2024-08-13T14:20:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-13T13:15:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-08T11:43:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-08T11:43:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Tropical Diseases, Travel Medicine and Vaccines","date":"2024-07-30T16:19:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"tropical-diseases-travel-medicine-and-vaccines","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tdtm","sideBox":"Learn more about [Tropical Diseases, Travel Medicine and Vaccines](http://tdtmvjournal.biomedcentral.com)","snPcode":"40794","submissionUrl":"https://submission.nature.com/new-submission/40794/3","title":"Tropical Diseases, Travel Medicine and Vaccines","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cd10565-2295-4d5f-9100-168ebc94ceea","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:02:36+00:00","versionOfRecord":{"articleIdentity":"rs-4830164","link":"https://doi.org/10.1186/s40794-024-00239-8","journal":{"identity":"tropical-diseases-travel-medicine-and-vaccines","isVorOnly":false,"title":"Tropical Diseases, Travel Medicine and Vaccines"},"publishedOn":"2025-03-01 15:57:14","publishedOnDateReadable":"March 1st, 2025"},"versionCreatedAt":"2024-09-16 16:51:44","video":"","vorDoi":"10.1186/s40794-024-00239-8","vorDoiUrl":"https://doi.org/10.1186/s40794-024-00239-8","workflowStages":[]},"version":"v1","identity":"rs-4830164","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4830164","identity":"rs-4830164","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}