Study highlights health risks to Bali tourists

Bali might look idyllic, but Monash University researchers
have reported on the vast health risks of travelling there.
Image source: Wikipedia

by Anne Crawford

Australians travelling to Bali would probably be familiar with the term “Bali belly” but while gastroenteritis or diarrhoea is a common illness for tourists they may not be aware that trauma and animal bites also pose a significant risk.

Now Monash University researchers have studied the spectrum of illness Australians bring home from the Indonesian island to better inform travellers on health risks and to assist clinicians in pre- and post-travel evaluations.


In a paper published in The Internal Medical Journal of the Royal Australasian College of Physicians, the researchers found that gastroenteritis accounted for 26% of people presenting to the emergency departments (ED) of Alfred Health, followed by 19% with systemic febrile illness (fever) and 11% with a respiratory tract infection. Five percent of total presentations had confirmed dengue fever, with most requiring inpatient admission for a short period of time. While 76% of those coming to ED with a fever were tested for malaria, none had the disease.

However, infectious diseases were only part of the picture.

Ten percent of patients had traumatic injuries while 6% had animal bites requiring rabies post-exposure vaccinations. The large majority had been bitten by a monkey, with 7% bitten by a dog and 3% by a bat.

“The study highlighted the fact that travellers probably weren’t being educated about the risks of trauma and animal bites and rabies,” said first author Dr Asma Sohail.

Of the traumatic injuries, most were caused by falls (53%), road traffic accidents (30%), water sport accidents (6%) and explosions (4%). Common diagnoses included fractures (64%) and head injury (9%) with 4% of patients suffering burns.

The risk of injury was likely partly attributable to the tourists being more likely to engage in high-risk behaviours (e.g. not wearing seatbelts or helmets, speeding, excessive alcohol consumption, and  participation in risky outdoor activities).

While most travellers presenting to the ED did not require an inpatient admission, suggesting that overall disease severity was generally mild, those presenting with a febrile illness were significantly more likely to be admitted compared to other diagnoses.

Dr Sohail said Department of Infectious Diseases researchers decided to conduct the study because limited literature was available on the subject. This was despite Indonesia being the second most visited country by Australians in 2018. More than one million passenger movements from major Australian cities to Denpasar have already been recorded this year.

“We see a lot of returning travellers from Bali in the emergency and outpatients departments, and also get a lot of calls from GPs, but there’s never been a big study looking at what sorts of illnesses these patients come back with,” Dr Sohail said. “This is the first large study that’s looked at returning Australian travellers from Bali.”

The researchers used a novel ‘text mining’ approach developed with scientists from the IT department to conduct the retrospective study of 464 adults presenting at the Alfred and Sandringham Hospital EDs over a five-year period to 31 December 2015. The tool allowed them to use particular words or text to identify patients who had been to Bali from ED triage notes, then allowing data collection from medical records.

The approach could be used to collate similar data about illness and injury to tourists in other countries, Dr Sohail said.

Based on the data, the study recommended that pre-travel consultation include
a discussion about common non-infectious risks associated with travel.

Professor Anton Peleg was the senior author on the paper.

Sohail A, McGuinness SL, Lightowler R, Leder K, Jomon B, Bain CA, Peleg AY. Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study. Intern Med J. 2018 Jun 5. doi: 10.1111/imj.13993. [Epub ahead of print]