344
ORIGINAL ARTICLE
Mortality Among Foreign Nationals in Chiang Mai City, Thailand,
2010 to 2011
Vichan Pawun, MD, MPH,∗† Surasing Visrutaratna, DDS, DrPH,‡ Kumnuan Ungchusak, MD,
MPH,§ Suteerat Mahasing, MA,‡ Chosita Khumtalord, MS,‡ Siriying Tipsriraj, MS,||
Chalermpol Chenwittaya, BA,|| Thomas E. Guadamuz, PhD,†¶ and Stephen R. Wisniewski,
PhD†
∗
Department of Disease Control, Bureau of General Communicable Disease, Ministry of Public Health, Nonthaburi, Thailand;
of Epidemiology, University of Pittsburgh Graduate School of Public Health (GSPH), Pittsburgh, PA, USA;
‡
Chiang Mai Provincial Public Health Office, Ministry of Public Health, Chiang Mai, Thailand; § Department of Disease
Control, Ministry of Public Health, Nonthaburi, Thailand; || Department of Disease Control, Office of Disease Prevention and
Control, 10th, Chiang Mai Province, Chiang Mai, Thailand; ¶ Center for Health Policy Studies, Faculty of Social Sciences and
Humanities, Mahidol University, Nakorn Pathom, Thailand
† Department
DOI: 10.1111/j.1708-8305.2012.00654.x
Background. Up to 65% of travelers to less developed countries report health problems while traveling. International travel is
an increasing concern for health practitioners. To date, there have not been any published analyses of mortality amongst foreign
nationals visiting Thailand. Our objectives are to examine the magnitude and characterize the deaths among foreign nationals in
Chiang Mai, a popular tourist province in Thailand.
Methods. The study commenced with a review of the Thai death registration. Death certificates were retrieved, reviewed, and
classified by the causes of death. Basic statistics and proportionate mortality ratio (PMR) were used to describe the pattern of
deaths. Standardized mortality ratio (SMR) was used to assess the excess mortality risk among foreign nationals.
Results. Between January 1, 2010 and May 31, 2011, there were 1,295 registered deaths in Chiang Mai City, of which 102 records
(7.9%) were foreign nationals. Median age of decedents was 64 years (range 14–102 y). Female-to-male ratio was 1 : 5.4. The
highest mortality was among Europeans (45.1%). Most of the deaths were natural causes (89.2%) including 36 cardiac diseases
(PMR = 35.3) and 20 malignancy diseases (PMR = 19.6). Deaths due to external causes were low. The SMRs range between 0.15
and 0.30.
Conclusion. Communicable diseases and injuries were not the leading causes of death among foreign nationals visiting Chiang
Mai, Thailand. It is essential that travelers are aware of mortality risk associated with their underlying diseases and that they are
properly prepared to handle them while traveling.
A
s overseas travel becomes more affordable, the
number of people traveling outside their home
countries has increased. According to data from
the United Nations World Tourism Organization,
approximately 880 million travelers visited foreign
countries in 2009.1 The number increased by 7%
in 2010, to 940 million travelers.1 The numbers of
international travelers visiting Southeast Asia has also
Corresponding Author: Vichan Pawun, MD, MPH, Department of Disease Control, Bureau of General Communicable Disease, Ministry of Public Health, Nonthaburi 11000,
Thailand. E-mail: vichpw@health2.moph.go.th
© 2012 International Society of Travel Medicine, 1195-1982
Journal of Travel Medicine 2012; Volume 19 (Issue 6): 344–351
increased significantly; by 2010, this region hosted 69.6
million travelers.1 Thailand hosted approximately 15.8
million in 2010, about 12.6% higher than in 2009.2
With the increase in international tourism, Thailand
has augmented its efforts to address health issues
related to international travel. The Thai government
commended the implementation of International
Health Regulations (IHR 2005), which entered into
effect in June 2007.3 In accordance with these
regulations (Annex 1 of the IHR 2005) the local public
health agencies shall utilize their resources to improve
their capacity of epidemiological surveillance to tracking
health problems among those residing and visiting their
jurisdiction.3,4
Mortality Analysis in Chiang Mai
Several factors contribute to morbidity and mortality
for international travelers. Individual characteristics,
behaviors, and underlying disease conditions of travelers
may increase or exacerbate the likelihood of a travelrelated health complication.5 Among travel-related
morbidity studies, Freedman reported the morbidity
rates for illness after traveling in developing countries
to be about 22% to 64%.6 Mortality studies among
international travelers are limited. The US Department
of State reports that over 6,000 Americans die abroad
each year.7 The Health Protection Agency Office in
the UK reports more than 4,000 British nationals die
abroad each year.8
In Thailand, epidemiological data on the health
status among international travelers are limited. Most
travel-related health research in Thailand has focused on
tropical diseases such as dengue hemorrhagic fever, and
malaria.9 – 11 There have not been any epidemiological
studies on international travelers who expire while
visiting Thailand. This is the first study to do so, and
we elected to examine mortality data among foreign
travelers in Chiang Mai Province, one of the most
frequented tourist destinations in Thailand. Chiang Mai
is one of 77 provinces in Thailand, and the provincial
city is about 700 km north of Bangkok, the capital
city of Thailand. The population was approximately 1.7
million in 2009. The province hosted approximately 4.3
million visitors in 2009, including 3.1 million Thais and
1.2 million foreign nationals.12
The primary objective of this study is to assess
characteristics, patterns, and causes of death among
foreign nationals in Chiang Mai City. The secondary
objective is to develop public health strategies to
monitor health problems among foreign nationals in
Thailand.
Methods
We assessed the mortality registration system in
Thailand from 1991 to 2010. The system flow of
the death registration was evaluated by reviewing
publicly available documents, official websites, and work
manuals.13 – 15 All registered deaths of foreign nationals
under the jurisdiction of the Chiang Mai Municipality
were manually reviewed. The Chiang Mai Municipality
is governed by an elected official, a ‘‘mayor,’’ that
oversees four administration offices in four divisions of
the Chiang Mai City. These included the administration
offices at the Sriwichai, Mengrai, Kawila, and
Nakhonping subdistricts.16 In order to gain permissions
to access the death certificates, an official letter was sent
to the respective mayor, and then allowance letters were
submitted to the chief officers of these four offices.
At the local offices, which do not utilize electronic
databases, all processes of data collection were based
on manually reviewing paper documents, including
logbook records of death registrations, accessing the
stored folders of death certificates, and extracting data
from the selected certificates. The selection criteria were
345
specified for all death records of non-Thai nationals, all
ages and genders from January 1, 2010 to May 31, 2011.
Certificates of death among immigrant workers were
excluded from this study.
Data Retrieval and Analysis
Data on nationality, age, gender, cause of death, place
of death, and date of death were extracted and recorded
using a standardized form. To ensure the confidentiality
of individuals, data with personal identifiers were not
collected. Local administrators supervised all data
extraction to ensure that confidentiality was observed.
Data analysis included the summary of the causes of
death, the proportion of death stratified by nationalities,
geographical continent, age group, and gender. As the
exact number of international travelers visiting Chiang
Mai City could not be determined, the mortality rates
among this specific population were not calculated. In
order to characterize the pattern of death, proportionate mortality ratio (PMR) was used to represent the
proportional comparisons of cause-specific death of all
registered deaths among foreign nationals. For the PMR
estimation, it is important to note that a high PMR of
death in one category will result in the low proportion
of another category.17 The study proposes to use the
standardized mortality ratio (SMR) as an epidemiological measure to assess risk of death among foreign
nationals in Chiang Mai City. The SMR was calculated
by totaling the actual observed number of deaths and
dividing it by the expected number of deaths.18,19 The
expected number of deaths was estimated by applying
the mortality rate in reference populations to the total
number of international arrivals by age group, which
include all types of international traveler arrivals (eg,
airport, seaport, and ground crossing).
International arrival data were collected from the
Ministry of Tourism and Sport’s database. This database
provides information about the number of foreign
nationals visiting Thailand by age group. However,
it does not provide such information in a specific
location. Hence, the total number of foreign nationals
visiting Chiang Mai City was assumed to be 10% of all
international arrivals, per the estimate provided by the
Chiang Mai Governor’s House.12
The reference mortality rates were taken from the
World Health Organization’s database.20 We utilized
the global population and the populations of the top
three nationalities in terms of frequency of deaths
in this study as the reference population. As most
mortality rates in our reference populations were the
annual death rates, an average length of stay among
international travelers visiting Thailand was about 9
days.21 Therefore, before applying the age-specific
death rates to population in each age group, we
converted the annual death rates to the 9-day-period
death rate. To do so, we assumed that mortality rates
in reference populations were constant throughout the
year.
J Travel Med 2012; 19: 344–351
346
Pawun et al.
Figure 1 Death registration system and flow of mortality data in Thailand.
Mortality System in Thailand
The Population Registration System is the source of
population demographic data in Thailand. The system
provides nationality status information including the
authentication of birth and death certificates. The Civil
Registration Act (No. 1) of B.E. 2534 and the additional
revision (No. 2) of B.E. 2551 specifies that all deaths
occur in Thailand must be registered within 24 hours
of being witnessed.
There is no specific death registration system for
foreign nationals. The process of death reporting and
registering is similar to the process for Thai citizens
(Figure 1). In cases of unknown or uncertain death,
the investigation officers are charged to investigate. As
pursuant to Thailand Criminal Procedure Code 148,
the investigative officials may conduct or request a
forensic autopsy to determine the cause of death before
issuing the investigation report to the next of kin. The
next of kin is then required to submit the report to the
local administration office to obtain an authenticated
death certificate.
For deaths occurring within medical establishments,
the attending physicians are authorized to issue the
medical certificate of death. The original medical
certificate of death is given to the next of kin, and a copy
is kept in the hospital files. The next of kin is required
to submit the medical death certificate to the local
J Travel Med 2012; 19: 344–351
administration office to obtain an authenticated death
certificate. All registered death records are automatically
sent to the central database at the Bureau of Registration
Administration, Ministry of Interior. This database is
shared with the Ministry of Public Health and the
National Statistical Office.12 – 15,22 As all authenticated
death certificates are issued in the official Thai language,
translated death certificates authorized by the embassy
or general consulate are helpful for the next of kin in
resolving assets and estate matters in their respective
countries.
The certification of death in Thailand classifies
deaths into three categories: death within medical
establishment due to medical illnesses; death outside
medical establishment due to natural causes; and death
due to unnatural or external causes such as suicides,
homicides, deaths from beastly attacks, deaths from
accidents, and deaths of unknown cause.13,14,22
Descriptive Analysis
During the 17-month study period, between January
1, 2010 and May 31, 2011, there were a total of 1,295
deaths registered in the Chiang Mai Municipality. Of
these 1,295 deaths, 102 (7.9%) were among non-Thai
nationals, with 66 deaths registered in 2010 (64.7%)
and 36 deaths registered in 2011 (35.3%). On average,
there were six (SD ± 3.52) deaths of foreign nationals
registered at Chiang Mai City each month. The median
347
Mortality Analysis in Chiang Mai
Table 1 Number and proportion of deaths among foreign nationals in Chiang Mai City by gender, age groups, and causes of
deaths, from January 1, 2010 to May 31, 2011 (N = 102)
Age group
Female
10–19
20–29
30–39
40–49
50–59
60–69
70–79
>80
Total
Male
10–19
20–29
30–39
40–49
50–59
60–69
70–79
>80
Total
Grand total
∗
†
Cardiac diseases
Malignant neoplasm
Infectious diseases
All other diseases∗
Unnatural causes
Total (%)
0
2
0
1
1
0
1
2
7 (43.7)
0
0
0
0
0
1
0
0
1 (6.3)
0
0
1
0
0
1
0
1
3 (18.7)
0
0
0
1
1
1
0
2
5 (31.3)
0
0
0
0
0
0
0
0
0 (0.0)
0 (0.0)
2 (12.5)
1 (6.3)
2 (12.5)
2 (12.5)
3 (18.7)
1 (6.3)
5 (31.3)
16 (15.7)†
0
0
0
3
5
11
6
4
29 (33.7)
36 (35.3)
1
0
0
0
5
6
6
1
19 (22.1)
20 (19.6)
0
0
0
1
1
2
1
4
9 (10.5)
12 (11.8)
0
2
0
1
2
7
3
3
18 (20.9)
23 (22.5)
0
3
1
3
3
1
0
0
11 (12.8)
11 (10.8)
1 (1.2)
5 (5.8)
1 (1.2)
8 (9.3)
16 (18.6)
27 (31.4)
16 (18.6)
12 (13.9)
86 (84.3)†
102 (100.0)
Other medical diseases include respiratory diseases, gastrointestinal disease, and other nonspecific medical condition.
Proportion of deaths among foreign nationals by gender.
age of death among foreign nationals was 64 years (range
14–102 y). The highest number of deaths was among
the 60 to 69 years age group (n = 30 deaths, 29.4%)
followed by 50 to 59 years (17.6%), 70 to 79 years
(16.7%), and over 80 years (16.7%) (Table 1).
The female-to-male ratio of death among non-Thai
nationals was 1 to 5.4. The region of residence and
nationalities of the decedents is shown in Table 2.
The largest number of deaths were among travelers
from Europe (46 deaths; 45.1%), followed by North
America (28 deaths; 27.5%), Asia (18 deaths; 17.7%),
and Australia and Oceania (9 deaths; 8.8%). Among
Europeans, the main countries of residence included the
UK (11 deaths; 23.9%) and Germany (9 deaths; 19.6%).
Among North American visitors, the United States had
the largest number of deaths in Chiang Mai City (25
deaths; 89.3%). For Australia and Oceania, Australia
had the highest number of deaths (8 deaths; 88.9%).
For Asia, there were 8 deaths (44.4%) of Japanese and 6
deaths (33.3%) of Chinese visitors.
Deaths from medical illnesses were predominant
for all age groups, accounting for 89.2% of all deaths.
Table 3 shows that medical illnesses were the main
cause of death among all foreign nationals. The
unnatural deaths were relatively high among Europeans
compared with other regions (p = 0.538). Suicide and
drug abuse-related deaths were highest among Australia
and Oceania compared with other regions (p < 0.001).
Figure 2 characterizes the cause-specific deaths
among foreign nationals in Chiang Mai City. Cardiovascular disease was the most common cause of
death among foreign nationals (36 cases; PMR = 35.3),
followed by malignant neoplasms (20 cases; PMR =
Table 2 Regional origin distribution of deaths among
foreign nationals in Chiang Mai City, from January 1, 2010 to
May 31, 2011 (N = 102)
Region
Number of
deaths (%)
Selected
countries
Number of
deaths per
country (%)
Europe
46 (45.10)
North America
28 (27.45)
Asia
18 (17.65)
UK
Germany
The Netherlands
France
The United States
Canada
Japan
China
Australia
New Zealand
—
11 (23.91)
9 (19.57)
7 (15.22)
5 (10.67)
25 (89.29)
3 (10.71)
8 (44.44)
6 (33.33)
8 (88.89)
1 (11.11)
—
Australia and Oceania
9 (8.82)
Unidentified
1 (0.98)∗
∗
There is one record of unknown nationality.
19.6), infections (12 cases; PMR = 11.8), and
cerebrovascular disease (6 cases; PMR = 5.9). Lung
infection and sepsis were the most common cause of
death from infections. Among the deaths that were
classified as unnatural causes, there were four accidental
deaths (PMR = 3.9), four suicides (PMR = 3.9), two
cases of drug overdose (PMR = 2.0), and one case
of drowning (PMR = 1.0). There was no record of
homicide during the study period. As shown in Table 4,
all of the expected deaths of foreign nationals, based
on different standard population death rates, are
greater than the observed number of deaths among
foreign nationals in Chiang Mai City. The SMRs range
between 0.15 and 0.30 (Table 5).
J Travel Med 2012; 19: 344–351
348
Pawun et al.
Table 3 Geographical distribution of deaths among foreign nationals in Chiang Mai City by the causes of death, from January
1, 2010 to May 31, 2011 (N = 102)
Region
Medical illnesses
Accident
Suicide
Drug overdose
Drowning
Total
40
27
18
5
1
91
4
0
0
0
0
4
1
1
0
2
0
4
0
0
0
2
0
2
1
0
0
0
0
1
46
28
18
9
1
102
Europe
North America
Asia
Australia and Oceania
None∗
Total
∗
There is one record of unknown nationality.
Cardiovascular diseases
Malignant neoplasms
Infectious diseases
Cerebrovascular disease
Gastrointestinal disease
Lung disease
All other diseases
Accidents
Suicide
Drug overdose
Drowning
Homicide
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Figure 2 The proportionate mortality ratios (PMRs) of each
cause-specific death among foreign nationals in Chiang Mai
City, from January 1, 2010 to May 31, 2011 (N = 102).
Discussion
The distribution of mortality among foreign travelers by
age and gender shows a similar pattern with the studies
conducted in Canada,23,24 the United States,25,26 and
Australia.27 The study reveals that mortality distribution
was predominant in older persons (≥50 y). This finding
might be as a result of the large number of senior
foreign nationals aged 50 years and above who reside
in Thailand. Data from the Thailand Immigration
Bureau show that the number of senior foreign nationals
approved for retirement visas to reside in Thailand
increased by 20% from 22,000 visas in 2008 to 27,000
visas in 2009.28 We found a much greater proportion
of deaths among male foreign nationals. However, this
is not a measurement of mortality rate, and therefore
it cannot imply that the risk of death among males is
higher than that of females.
A significant finding of our study was that the
leading causes of death among foreign nationals less
than 50 years were medical illnesses. Cardiovascular
disease was the leading cause of death, accounting for
approximately 35%, which is consistent with studies of
travelers from Australia, Canada, the United States, and
Scotland.23 – 27,29,30 We also found malignancy deaths
ranked second among all causes of deaths, accounting
for approximately 20%. This finding differs from many
previously cited studies, but it was similar to the findings
of Leggat and Wilks in Australia.27
J Travel Med 2012; 19: 344–351
We applied the SMRs to examine whether foreign
nationals in Chiang Mai City have a higher mortality
than one would expect in their home countries.
Surprisingly, we found that no matter what the choice
of reference populations, the results yielded very low
SMRs. All of the calculated SMRs are less than
1, indicating that the mortality risk among foreign
nationals visiting Chiang Mai City did not exceed
mortality risk as compared with the risk in their home
countries. In other words, there was no evidence of any
increased risk of death from residing in or traveling to
Chiang Mai City.
There were several assumptions and limitations
in this study. First, because there is no specific
death registry for foreign nationals, the administrative
database was assumed to be the complete database for
all foreign nationals. We also assumed that the accuracy
and completeness of death registration data for foreign
nationals were similar to the registration data for Thai
citizens. According to Tangcharoensathien et al.’s study
in 2006, the completeness of the death registration
in Thailand was high with 95% completeness of
registration; however, only 30% of the causes of
death described in the registers matched the causes
determined by the medical review.31 These inherent
limitations of the death registry may impact the accuracy
of our study’s results. Second, the study was unable to
determine the exact number of foreign nationals visiting
Chiang Mai City and it was unable to distinguish shortterm travelers from long-term travelers (stay of ≥6 m).
As a result, the mortality rate of foreign nationals was
unable to be determined. Finally, the mortality rates
in reference populations were assumed to be constant
throughout the year. This assumption may influence an
accuracy of the SMR estimation.
Disease exacerbation among individuals with chronic
illnesses while traveling is not unexpected. Seeking
pre-travel consultation early, at least 4 to 6 weeks
prior to departure is recommended for all travelers
with underlying diseases.32 Our results indicate that
infections were not the common cause of travel-related
death in Thailand, thus health professionals should
highlight the likelihood of disease exacerbation and
provide a proper preparation for travelers, rather than
focusing on antimalarial or antibiotic prophylaxis. In
order to gain a better understanding of travelers’ health
349
Mortality Analysis in Chiang Mai
Table 4
rates
Comparison of the expected deaths and observed deaths among foreign nationals using different standard population
Age group
Approximate
numbers of foreign
nationals in Chiang
Mai City∗
UK
population
death rate†
(per 100,000)
US
population
death rate†
(per 100,000)
AUS
population
death rate†
(per 100,000)
Global
population
death rate†
(per 100,000)
Under 15
15–24
25–34
35–44
45–54
55–64
>65
Total
59,767
155,624
385,135
343,223
276,758
166,322
59,594
1,446,423
0.31
0.94
1.60
3.22
7.03
17.24
254.71
0.48
1.90
2.53
4.40
10.17
21.61
235.12
0.37
1.47
2.16
3.29
6.99
16.57
270.57
4.80
4.88
7.02
11.22
23.18
51.74
348.67
Observed deaths
among foreign
nationals‡
1
0
4
1
12
16
32
66
Age group
Approximate
numbers of foreign
nationals in Chiang
Mai City∗
Expected
deaths based
on UK
population
Expected
deaths based
on US
population
Expected
deaths based
on AUS
population
Expected
deaths based
on global
population
Observed
deaths among
foreign
nationals‡
Under 15
15–24
25–34
35–44
45–54
55–64
>65
Total
59,767
155,624
385,135
343,223
276,758
166,322
59,594
1,446,423
0.19
1.46
6.17
11.04
19.45
28.67
151.79
218.77
0.28
2.95
9.73
15.11
28.15
35.95
140.12
232.29
0.22
2.28
8.31
11.30
19.35
27.56
161.24
230.26
2.87
7.60
27.02
38.51
64.15
86.06
207.79
433.98
1
0
4
1
12
16
32
66
∗
The approximate numbers of foreign nationals visiting Chiang Mai were estimated from the 10% of total international arrivals in Thailand in 2007 (most updated data)
from the Department of Tourism, Ministry of Tourism and Sports.
†
The 9-d-period period population mortality rates. These rates were estimated from the annual death rates of the reference populations in 2009 (most recent database)
published by the World Health Organization.
‡
The observed number of deaths among foreign nationals in Chiang Mai City in 2010 (1-y period).
Table 5 Comparison of the standardized mortality ratios
using different standard populations
Choice of standard population rate
SMR∗
95% confidence
interval
UK population death rate
US population death rate
AUS population death rate
Global death rate
0.30
0.28
0.29
0.15
0.09–0.51
0.16–0.41
0.08–0.49
0.11–0.19
∗
The standardized mortality ratio (SMR) is defined as SMR = observed number
of deaths among foreign nationals per year/expected number of deaths among
foreign nationals per year.
and provide an appropriate health intervention for
international travelers, host countries should strengthen
their capacity to monitor health status among this
specific population using the most accurate and
applicable approach. Updating information of the
characteristics of travelers’ risks and understanding
characteristics of health problems among foreign
nationals will be useful for expanding epidemiological
knowledge on providing a better prepared public health
infrastructure that may include accessible emergency
services as well as targeted prevention programs. In
Thailand, we recommended that both national and local
health authorities utilize a vital statistic for monitoring
health status among foreign nationals and review this
statistic frequently. The usefulness of this statistic can be
strengthened by increasing completeness and accuracy
of the death records, as well as checking consistency
with medical or autopsy data.
Conclusion
Increasing our understanding of travel-related risks
and how they relate to mortality is important to
improve preventive responses. It is valuable to know
the characteristics of deaths among foreign nationals
visiting Thailand because this information can be
used for identifying high-risk travelers and high-risk
activities and for developing specific interventions to
reduce likelihood of overseas mortality. This study
has produced encouraging results in identifying the
potential value of exploring the vital statistics and
tourism statistics to estimate mortality risk among
foreign nationals in Thailand. It is however only a
first step. Further work at national level will be needed
to validate the findings of this study.
Our results suggest that the risk of overseas mortality
among foreign nationals visiting Chiang Mai City was
not high as compared with the mortality risk in their
home countries. Hence, Chiang Mai City may not be
J Travel Med 2012; 19: 344–351
350
a high-risk destination for foreign nationals. The common causes of death among foreign nationals visiting
Chiang Mai City were not infections or injuries, but the
major causes of death were chronic illnesses such as cardiovascular diseases and malignancies. It is essential that
travelers are aware of the mortality risk associated with
chronic diseases and that they are properly prepared to
handle them. We recommend that travelers who have
chronic diseases should seek medical advice and prepare
for a risk of disease exacerbation while traveling. Health
care providers should underline the importance of
pre-travel planning for persons with underlying diseases.
Contributing to the literature of travel epidemiology,
particularly for Thailand, will be useful for improving
better health advocacy for travelers. Public health practitioners should outline the usefulness of travel epidemiology and the importance of pre-travel consultation.
Acknowledgments
We would like to thank many individuals who
have made this study possible. We are especially
grateful to the mayor of Chiang Mai City; the chief
officers of Sriwichai, Mengrai, Kawila, and Nakhonping
subdistricts; a director of the Bureau of Epidemiology;
a director and all staffs in the Field Epidemiology
Training Program (FETP) Thailand; and all officials
at Chiang Mai Health Office and the Office of
Disease Prevention and Control Region 10, Chiang
Mai Province.
Declaration of Interests
The authors state that they have no conflicts of interest
to declare.
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Wat Arun Pagoda on the west bank of the Chao Phraya river in Bangkok is a much-frequented tourist spot. Thailand is one of the
most popular tourist destinations, with more than 20.5 million tourist arrivals annually. Photo Credit: Nicolas Bossard (Setting: Wat
Arun Pagoda, Bangkok, Thailand)
J Travel Med 2012; 19: 344–351