Travel Medicine and Infectious Disease xxx (xxxx) xxx–xxx

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Travel Medicine and Infectious Disease
journal homepage: www.elsevier.com/locate/tmaid

Japanese tourists travelling in India have poor pre-travel preparedness
Dear Editor,Illness or injury while travelling forces travellers to change or cancel
their planned itinerary, and brings a range of other disadvantages. In
Western countries, travel medicine is well recognised [1]. Tourists fromthose countries take more preventive measures before trips, such as
seeking pre-travel health advice and pre-travel vaccinations than Asiantravellers [2,3]. In contrast, travel medicine is less recognised in Japan,
and the travel-related vaccination rate is much lower in Japanese travellers [4–7]. This situation may increase Japanese travellers' risk forcontracting diarrhoea and other health problems during and after theirtrips. Therefore, we considered it was necessary to clarify possible risk
factors for common traveller's illnesses and injuries, and provide evidence-based travel-related health information for the beneﬁt of travellers, health authorities and health practitioners. Such information
will help to prevent travellers' illness or injury while travelling, andenable them to travel safely according to their planned schedule. Thus,
we preliminarily investigated the characteristics of Japanese backpackers travelling in India and their risk preparedness status against
health problems.
We collected data at the guesthouse in Delhi, India. This guesthouse
is located in Paharganj, in the centre of New Delhi and provides inexpensive accommodation for Japanese tourists. The survey was conducted from 2 February 2018 to 31 March 2018. Participants eligible
for this study were Japanese tourists aged 18–80 years at the time ofproviding informed consent, who were staying at the guesthouse. We
used a web-based questionnaire service (Questant, Macromill, Inc.
Tokyo, Japan) to collect data from survey participants because thehigher response rate than a paper-based questionnaire was expectedfrom our preliminary surveys including interviews to the guesthousestaﬀ and travellers. Participants accessed the questionnaire website
using the tablet devices provided or their own device. The survey
covered: participants' general information (e.g. age, sex, occupation);
information on their present visit to India (e.g. date of entry); history oftravelling overseas; history of travelling in India; and risk preparedness
status against illness and injury in the present trip (i.e. collecting information on health and safety before departure, having travel-related
vaccinations in the past and for the present trip, bringing anti-diarrhoeal medicines and antibiotics on the present trip). The sources ofinformation covered were friends/acquaintances, travellers' blog/websites, travel agencies, guidebooks, websites of Ministry of Foreign
Aﬀairs, Japan, Websites of Ministry of Health, Labour and Welfare,Japan, and Websites of overseas oﬃcial bodies. The vaccinations covered were hepatitis A, hepatitis B, tetanus, rabies, yellow fever,Japanese encephalitis, typhoid, polio, meningococcus, and others. We
summarised participants’ characteristics and risk preparedness status
by descriptive statistics using Stata statistical software (Stata SE version
12.1, Stata Corp LP, TX, USA). Approval for this study was obtained
from the Institutional Ethics Committee of Okayama University

Graduate School of Medicine, Dentistry and Pharmaceutical Sciencesand Okayama University Hospital (No. Ken-1509-027).
There were 98 participants in the survey. The mean age (standarddeviation, range) was 25.7 years (6.5 years, 19–50 years). The sex ratio
was almost equal, although the proportion of males was a little higher(55.1%). Almost half of the participants were students (49.0%).
Although most participants had experience of travelling overseas before
their present trip (88.8%), most were visiting India for the ﬁrst time(84.7%). Table 1 shows participants' risk preparedness status. In total
66.3% of participants had collected information related to health andsafety before departure. Sources of information that were frequently
used were travellers’ blogs/websites, guidebooks and friends/acquaintances. Websites of oﬃcial bodies were less used information sources:
Ministry of Foreign Aﬀairs, Japan (21.5%); Ministry of Health, Labourand Welfare, Japan (6.2%); and overseas oﬃcial bodies such as USCenters for Disease Control and Prevention and the World Health Organization (7.7%). In total, 27.6% of participants had received vaccinations in the past and 11.2% had been vaccinated for their presenttrip. The vaccination received most frequently for the present trip was
hepatitis A (9.2%). The proportions of participants who brought antidiarrhoeal medicines and antibiotics were 34.7% and 16.3%, respectively. Overall, 82.7% of participants had taken any one of the above
ﬁve measures.
In the present study, we found that Japanese travellers were travelling in India without suﬃcient risk preparation, especially in having
travel-related vaccinations. Our result is consistent with previous studies [4–7], and conﬁrms the lack of immunisation among Japanesetravellers. About two-thirds of our participants had collected pre-travel
information on health and safety. Commonly used information sourceswere traveller's blogs/websites, guidebooks and friends/acquaintances.
In contrast, information from oﬃcial bodies was less accessed. Somemeasures should be taken to inform travellers about the existence ofreliable information for travelling (e.g. oﬃcial bodies' websites) andencourage them to access this information.
The number of foreign tourists in India has continuously increased.
Our study will contribute to improving the health and safety of travellers to India as well as other countries by identifying risk factors anddisseminating preventive measures against illness and injury during
travel.
Financial support
This study was partly supported by the Joint Usage/Research Center
on Tropical Disease, Institute of Tropical Medicine, Nagasaki University[grant number: 29-Ippan-4].
Conﬂicts of interest
None.

https://doi.org/10.1016/j.tmaid.2019.05.003
Received 19 March 2019; Received in revised form 26 April 2019; Accepted 3 May 20191477-8939/ © 2019 Elsevier Ltd. All rights reserved.

Travel Medicine and Infectious Disease xxx (xxxx) xxx–xxxThe study protocol and the contents of the questionnaires werecreated by MY, TT and AT with the help of MH. Recruitment of participants and data collection on site was done by AT. Descriptive statistics
was performed by AT. Interpretation of the results was done by allauthors. All authors have read and approved the ﬁnal manuscript forpublication.

Table 1
Participants’ risk preparedness status.
Participants
N = 98
Collecting information on health and safety, n (%)
NoYes
Sources of information, n (%)aFriends/acquaintances
Travellers' blogs, websites, etc.
Travel agencies
Guidebooks
Websites of Ministry of Foreign Aﬀairs, Japan
Websites of Ministry of Health, Labour and Welfare, Japan
Websites of overseas oﬃcial bodiesb
Having travel-related vaccination in the past, n (%)
No
Yes
Types of vaccination, n (%)
Hepatitis A
Hepatitis B
Tetanus
RabiesYellow fever
Japanese encephalitis
Typhoid
Polio
Meningococcus
OthersHaving travel-related vaccination for the present trip, n (%)
No
Yes
Types of vaccination, n (%)
Hepatitis A
Hepatitis B
Tetanus
RabiesYellow fever
Japanese encephalitis
Typhoid
Polio
Meningitis
OthersBringing anti-diarrhoeal medicines, n (%)
NoYesBringing antibiotics, n (%)
NoYes
Any of above ﬁve measures
NoYes

3365(33.7)(66.3)

Acknowledgments

2637630144
5(40.0)(56.9)(9.2)(46.2)(21.5)(6.2)(7.7)

We thank all participants for their cooperation, and the staﬀ ofSantana Delhi Guesthouse and Santana Varanasi Guesthouse for theirvaluable support. We also thank Audrey Holmes, MA, from Edanz
Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

7127(72.5)(27.6)

19814131397612(19.4)(8.2)(14.3)(13.3)(13.3)
(9.2)
(7.1)
(6.1)
(1.0)
(2.0)

87
11(88.8)(11.2)

90447341
10(9.2)
(0.0)
(4.1)
(4.1)
(7.1)
(3.1)
(4.1)
(1.0)
(1.0)
(0.0)

64
34(65.3)(34.7)

82
16(83.7)(16.3)

1781(17.4)(82.7)

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Akiko Tokinobu∗
Department of Primary Care and Medical Education, Okayama University
Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1
Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
E-mail address: tokichin@okayama-u.ac.jp.
Michiyo Yamakawa
Department of Epidemiology and Preventive Medicine, Gifu University
Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
E-mail address: myamak@gifu-u.ac.jp.
Toshihide Tsuda
Department of Human Ecology, Okayama University Graduate School ofEnvironmental and Life Science, 3-1-1 Tsushima-naka, Kita-ku, Okayama,700-8530, Japan
E-mail address: tsudatos@md.okayama-u.ac.jp.
Naohiko Matsushita
Department of Paediatric Infectious Diseases, Institute of Tropical Medicine,
Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
E-mail address: naomatsu2@yahoo.co.jp.

Percentage of participants among those who answered “Yes” to the question about whether they had collected information on health and safety.
bOﬃcial bodies such as Centers for Disease Control and Prevention (US) andthe World Health Organization.
aMasahiro Hashizume
Department of Paediatric Infectious Diseases, Institute of Tropical Medicine,
Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
E-mail address: hashizum@nagasaki-u.ac.jp.

Author's contribution
All authors contributed to the study.

∗2

Corresponding author.