Vehicles of travel

Outbreaks in travelers can be traced to infection acquired in the vehicle of travel - en route transmission. Food-borne outbreaks (e.g. salmonellosis, shigellosis, cholera, staphylococcal food poisoning, and others) have been linked to food or beverages served on flights (Mangili and Gendreau, 2005). Infections transmitted directly from person to person, and those that are airborne, also pose a risk to airplane travelers. Published reports describe transmission of tuberculosis, SARS, measles, and influenza on aircraft. In one outbreak, 72 percent of 54 passengers on a plane that had been grounded for Three hours because of a failed air-circulation system developed influenza-like illness; influenza A was documented (Moser et al., 1979). Norovirus, a cause of acute gastroenteritis, has probably also been transmitted on an airplane (Widdowson et al., 2005). Following a single 3-hour flight between Hong Kong and Beijing that included an ill passenger who later died of SARS, confirmed or probable SARS developed in 18 of 120 passengers. Those seated within three rows in front of the index case were most likely to become infected (Olsen et al, 2003).

People tend to think of cruises as an outdoor activity, but on large cruise ships passengers spend much time in indoor shared spaces. Gastrointestinal infections have long been associated with cruise ships, but more recently outbreaks of other infections have been reported (Minooee and Rickman, 1999). These include legionellosis (CDC, 2005d; Kura et al., 2006) and infections, like influenza (Brotherton et al., 2003) and rubella, with person-to-person spread. Noroviruses have emerged as a major problem for cruise ships. Not only can these viruses be spread from person to person by fecal-oral transmission and airborne transmission, they can also be spread via contaminated food and water and by contact with contaminated surfaces in the environment (Bull et al., 2006). They can persist in the environment despite disinfection efforts (Widdowson et al., 2005). New virus variants have emerged and have been associated with an increase in outbreaks on cruise ships (Lopman et al., 2004; Widdowson et al., 2004). The dispersal of passengers after cruise-ship travel may allow seeding of multiple communities with infections.

Persons who are older and have chronic medical problems make up a high percentage of travelers on some cruises. On one cruise ship with an outbreak of influenza, 77.4 percent of 1448 passengers were 65 years of age or older, and 26.2 percent had chronic medical problems (CDC, 1997).

The arrival of travelers changes places and affects the host population. This can occur through building hotels, providing food and other services for travelers, building new roads, and changing the habitat or landscape to make it more desirable to visitors. These activities can bring economic benefits to a region and provide new jobs for local residents. There are also negative consequences -destruction of pristine habitats, alteration of ecosystems and fragmentation of habitats; increased traffic and pollution; increased inequalities; disruption or corruption of local activities and customs; sexual tourism; and increased crime as wealthy tourists have close contact with impoverished local residents. Much of the wealth from tourism to a region may flow out of the country in cases where hotels and other concessions are owned by foreign investors.

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