Direct Medical Costs of 3 Reportable Travel-Related Infections in Ontario, Canada, 2012–2014

Rachel D. Savage; Laura C. Rosella; Natasha S. Crowcroft; Maureen Horn; Kamran Khan; Laura Holder; Monali Varia


Emerging Infectious Diseases. 2019;25(8):1501-1510. 

In This Article

Abstract and Introduction


Immigrants traveling to their birth countries to visit friends or relatives are disproportionately affected by travel-related infections, in part because most preventive travel health services are not publicly funded. To help identify cost-effective policies to reduce this disparity, we measured the medical costs (in 2015 Canadian dollars) of 3 reportable travel-related infectious diseases (hepatitis A, malaria, and enteric fever) that accrued during a 3-year period (2012–2014) in an ethnoculturally diverse region of Canada (Peel, Ontario) by linking reportable disease surveillance and health administrative data. In total, 318 case-patients were included, each matched with 2 controls. Most spending accrued in inpatient settings. Direct healthcare spending totaled $2,058,196; the mean attributable cost per case was $6,098 (95% CI $5,328–$6,868) but varied by disease (range $4,558–$7,852). Costs were greatest for enteric fever. Policies that address financial barriers to preventive health services for high-risk groups should be evaluated.


Because of the rapid growth of air travel and immigration, more travelers worldwide are exposed to nonendemic infectious diseases (e.g., Zika, measles, malaria) than ever before.[1–3] In Ontario, Canada, >3,000 travel-related infections are reported to public health annually;[4] this number is an underestimate because not all sick persons seek healthcare treatment, especially while traveling, and not all conditions are diagnosed and reported. Immigrant travelers who return to their birth countries to visit friends or relatives are a substantial risk group.[5] In Canada and elsewhere, regions with high proportions of immigrant travelers to South Asia and Africa have the highest rates of imported cases of hepatitis A, malaria, and enteric fever.[4,6–8] The disproportionate burden of travel-related infections in immigrants has been attributed to their traveling to riskier destinations[9] and prolonged travel stays[10,11] but also to their poor uptake of pretravel health services.[10,12–14]

Pretravel health consultations provide an opportunity to intervene and reduce travel-related infections.[14] The Committee to Advise on Tropical Medicine and Travel recommends that nonimmune travelers going to developing countries receive the hepatitis A vaccine,[15] travelers going to South Asia receive the typhoid vaccine,[16] and travelers going to regions where malaria is endemic receive chemoprophylaxis[17] before traveling. Despite these recommendations, pretravel health services are generally not covered by provincial universal insurance plans, with few exceptions.[18] Private health insurance can fill these gaps by providing partial or complete coverage for these services; however, many travelers, including those visiting friends or relatives (VFR), who are at greater risk for infection, often do not have private insurance. The cost of pretravel health services has been described by VFR travelers as a barrier.[9,19–22] As a result, public health officials have advocated for universal coverage of pretravel health services to reduce the substantial public health resources required for the management of these imported cases.[6,23]

The direct medical costs of reportable travel-related infections to healthcare systems has not been measured. The existing estimates were determined primarily by using inpatient settings or are considered outdated.[24–26] As outbound travel and annual immigration targets continue to increase, evidence is needed to determine if policies are meeting the healthcare needs of an increasingly diverse population. Furthermore, mathematic and economic models require this information as inputs, so the lack of cost estimates has limited the development of these models. In this report, we sought to measure healthcare utilization and attributable medical costs of 3 key reportable travel-related infections in an ethnoculturally diverse region of Canada by linking public health reportable disease surveillance data with health administrative data.