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Kantele A, Riekkinen M, Jokiranta TS, Pakkanen SH, Pietilä JP, Patjas A, Eriksson M, Khawaja T, Klemets P, Marttinen K, Siikamäki H, Lundgren A, Holmgren J, Lissmats A, Carlin N, Svennerholm AM. Safety and immunogenicity of ETVAX®, an oral inactivated vaccine against enterotoxigenic Escherichia coli diarrhoea: a double-blinded, randomized, placebo-controlled trial amongst Finnish travellers to Benin, West Africa. J Travel Med 2023; 30:taad045. [PMID: 37099803 PMCID: PMC10658657 DOI: 10.1093/jtm/taad045] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/31/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND No licensed human vaccines are available against enterotoxigenic Escherichia coli (ETEC), a major diarrhoeal pathogen affecting children in low- and middle-income countries and foreign travellers alike. ETVAX®, a multivalent oral whole-cell vaccine containing four inactivated ETEC strains and the heat-labile enterotoxin B subunit (LTB), has proved promising in Phase 1 and Phase 1/ 2 studies. METHODS We conducted a Phase 2b double-blinded, randomized, placebo-controlled trial amongst Finnish travellers to Benin, West Africa. This report presents study design and safety and immunogenicity data. Volunteers aged 18-65 years were randomized 1:1 to receive ETVAX® or placebo. They visited Benin for 12 days, provided stool and blood samples and completed adverse event (AE) forms. IgA and IgG antibodies to LTB and O78 lipopolysaccharide (LPS) were measured by electrochemiluminescence. RESULTS The AEs did not differ significantly between vaccine (n = 374) and placebo (n = 375) recipients. Of the solicited AEs, loose stools/diarrhoea (26.7/25.9%) and stomach ache (23.0/20.0%) were reported most commonly. Of all possibly/probably vaccine-related AEs, the most frequent were gastrointestinal symptoms (54.0/48.8%) and nervous system disorders (20.3/25.1%). Serious AEs were recorded for 4.3/5.6%, all unlikely to be vaccine related. Amongst the ETVAX® recipients, LTB-specific IgA antibodies increased 22-fold. For the 370/372 vaccine/placebo recipients, the frequency of ≥2-fold increases against LTB was 81/2.4%, and against O78 LPS 69/2.7%. The majority of ETVAX® recipients (93%) responded to either LTB or O78. CONCLUSIONS This Phase 2b trial is the largest on ETVAX® undertaken amongst travellers to date. ETVAX® showed an excellent safety profile and proved strongly immunogenic, which encourages the further development of this vaccine.
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Affiliation(s)
- Anu Kantele
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
- Human Microbiome Research Unit, University of Helsinki, Helsinki, Finland
- Travel Clinic, Aava Medical Center, Helsinki, Finland
| | - Marianna Riekkinen
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
- Human Microbiome Research Unit, University of Helsinki, Helsinki, Finland
- Travel Clinic, Aava Medical Center, Helsinki, Finland
| | - T Sakari Jokiranta
- United Medix Laboratories/Synlab Finland Ltd, Helsinki, Finland
- Medicum, Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland
- Mobidiag Ltd, Espoo, Finland
| | - Sari H Pakkanen
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
- Human Microbiome Research Unit, University of Helsinki, Helsinki, Finland
| | - Jukka-Pekka Pietilä
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
- Human Microbiome Research Unit, University of Helsinki, Helsinki, Finland
- Travel Clinic, Aava Medical Center, Helsinki, Finland
| | - Anu Patjas
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
- Human Microbiome Research Unit, University of Helsinki, Helsinki, Finland
- Travel Clinic, Aava Medical Center, Helsinki, Finland
| | - Mari Eriksson
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
| | - Tamim Khawaja
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
- Human Microbiome Research Unit, University of Helsinki, Helsinki, Finland
| | - Peter Klemets
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
| | - Kati Marttinen
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
| | - Heli Siikamäki
- Meilahti Vaccine Research Center, MeVac, University of Helsinki and Department of Infectious Diseases, Inflammation Center, HUS, Helsinki University Hospital, Helsinki, Finland
| | - Anna Lundgren
- Gothenburg University Vaccine Research Institute, Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Jan Holmgren
- Gothenburg University Vaccine Research Institute, Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Ann-Mari Svennerholm
- Gothenburg University Vaccine Research Institute, Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
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Yamakawa M, Tsuda T, Wada K, Nagata C, Suzuki E. Diarrhea and related personal characteristics among Japanese university students studying abroad in intermediate- and low-risk countries. PLoS One 2023; 18:e0279426. [PMID: 36827397 PMCID: PMC9956663 DOI: 10.1371/journal.pone.0279426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/06/2022] [Indexed: 02/26/2023] Open
Abstract
Despite an increasing number of students studying abroad worldwide, evidence about health risks while they are abroad is limited. Diarrhea is considered the most common travelers' illness, which would also apply to students studying abroad. We examined diarrhea and related personal characteristics among Japanese students studying abroad. Japanese university students who participated in short-term study abroad programs between summer 2016 and spring 2018 were targeted (n = 825, 6-38 travel days). Based on a 2-week-risk of diarrhea (passing three or more loose or liquid stools per day) among travelers by country, the destination was separated into intermediate- and low-risk countries. After this stratification, the associations between personal characteristics and diarrhea during the first two weeks of their stay were evaluated using logistic regression models. Among participants in intermediate-risk countries, teenagers, males and those with overseas travel experience were associated with an elevated risk of diarrhea; the odds ratios (95% confidence intervals) were 2.42 (1.08-5.43) for teenagers (vs. twenties), 1.93 (1.08-3.45) for males (vs. females) and 2.37 (1.29-4.33) for those with overseas experience (vs. none). Even restricting an outcome to diarrhea during the first week did not change the results substantially. The same tendency was not observed for those in the low-risk countries. Teenage students, males and those with overseas travel experience should be cautious about diarrhea while studying abroad, specifically in intermediate-risk countries.
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Affiliation(s)
- Michiyo Yamakawa
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
- Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
- * E-mail:
| | - Toshihide Tsuda
- Department of Human Ecology, Graduate School of Environmental and Life Science, Okayama University, Okayama, Japan
| | - Keiko Wada
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Chisato Nagata
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Etsuji Suzuki
- Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Li S, Han X, Upadhyay I, Zhang W. Characterization of Functional B-Cell Epitopes at the Amino Terminus of Shigella Invasion Plasmid Antigen B (IpaB). Appl Environ Microbiol 2022; 88:e0038422. [PMID: 35856689 PMCID: PMC9361828 DOI: 10.1128/aem.00384-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/29/2022] [Indexed: 01/22/2023] Open
Abstract
Shigella invasion plasmid antigen B (IpaB) plays an important role in causing shigellosis. While IpaB's protein structure, contribution to disease mechanism, and protective immunity against Shigella infection have been well studied, the significance of individual antigenic domains, especially at the N terminus, has not been systematically characterized. In an attempt to identify IpaB protein functional epitopes and to construct an optimized polyvalent multiepitope fusion antigen (MEFA) immunogen for development of a protein-based cross protective Shigella vaccine, in this study, we in silico identified immunodominant B-cell epitopes from the IpaB N terminus, fused each epitope to carrier protein CsaB (the major subunit of enterotoxigenic Escherichia coli CS4 adhesin) for epitope fusion proteins, immunized mice with each epitope fusion protein, examined IpaB-specific antibody responses, and assessed antibody functional activity against Shigella bacterial invasion. A total of 10 B-cell continuous epitopes were identified from IpaB N terminus, and after being fused to carrier protein CsaB, each epitope induced anti-IpaB IgG responses in the intramuscularly immunized mice. While in vitro antibody invasion inhibition assays demonstrated that antibodies derived from each identified epitope were functional, epitopes 1 (LAKILASTELGDNTIQAA), 2 (HSTSNILIPELKAPKSL), and 4 (QARQQKNLEFSDKI) induced antibodies to inhibit Shigella sonnei and Shigella flexneri invasion at levels similar to those of recombinant IpaB protein, suggesting that these three IpaB epitopes can be used potentially as IpaB-representing antigens to induce protective anti-IpaB antibodies and for construction of an epitope-based polyvalent MEFA protein immunogen for Shigella vaccine development. IMPORTANCE Currently, there are no effective measures for control or prevention of Shigella infection, the most common cause of diarrhea in children 3 to 5 years of age in developing countries. Challenges in developing Shigella vaccines include virulence heterogeneity among species and serotypes. To overcome virulence heterogeneity challenge and to develop a protein-based multivalent Shigella vaccine, we targeted a panel of virulence factors, including invasion plasmid antigens, identified functional antigenic domains or epitopes as representative antigens, and applied the novel epitope- and structure-based vaccinology platform multiepitope fusion antigen (MEFA) to integrate functional antigenic domains or epitopes into a backbone immunogen to produce a polyvalent immunogen for cross protective antibodies. Identification of functional IpaB epitopes from this study enhances our understanding of IpaB immunogenicity and allows us to directly utilize IpaB epitopes for construction of a cross protective polyvalent Shigella immunogen and to accelerate development of a protein-based Shigella vaccine.
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Affiliation(s)
- Siqi Li
- Department of Pathobiology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Xinfeng Han
- Department of Pathobiology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Sichuan Agricultural University College of Veterinary Medicine, Chengdu, Sichuan, People’s Republic of China
| | - Ipshita Upadhyay
- Department of Pathobiology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Weiping Zhang
- Department of Pathobiology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
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Doxycycline as an antimalarial: Impact on travellers' diarrhoea and doxycycline resistance among various stool bacteria - Prospective study and literature review. Travel Med Infect Dis 2022; 49:102403. [PMID: 35872253 DOI: 10.1016/j.tmaid.2022.102403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/18/2022] [Accepted: 07/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Antibiotics predispose travellers to acquire multidrug-resistant bacteria, such as extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE). Although widely used in antimalarial prophylaxis, doxycycline has scarcely been studied in this respect. METHODS We explored the impact of doxycycline on rates of traveller's diarrhoea (TD), ESBL-PE acquisition and, particularly, doxycycline co-resistance among travel-acquired ESBL-PE in a sample of 412 visitors to low- and middle-income countries. We reviewed the literature on traveller studies of doxycycline/tetracycline resistance among stool pathogens and the impact of doxycycline on TD rates, ESBL-PE acquisition, and doxycycline/tetracycline resistance. RESULTS The TD rates were similar for doxycycline users (32/46; 69.6%) and non-users (256/366; 69.9%). Of the 90 travel-acquired ESBL-PE isolates, 84.4% were co-resistant to doxycycline: 100% (11/11) among users and 82.3% (65/79) among non-users. The literature on doxycycline's effect on TD was not conclusive nor did it support a recent decline in doxycycline resistance. Although doxycycline did not increase ESBL-PE acquisition, doxycycline-resistance among stool pathogens proved more frequent for users than non-users. CONCLUSIONS Our prospective data and the literature review together suggest the following: 1) doxycycline does not prevent TD; 2) doxycycline use favours acquisition of doxy/tetracycline-co-resistant intestinal bacteria; 3) although doxycycline does not predispose to travel-related ESBL-PE acquisition per se, it selects ESBL-PE strains co-resistant to doxycycline; 4) doxycycline resistance rates are high among stool bacteria in general with no evidence of any tendency to decrease.
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Lόpez-Vélez R, Lebens M, Bundy L, Barriga J, Steffen R. Bacterial travellers' diarrhoea: A narrative review of literature published over the past 10 years. Travel Med Infect Dis 2022; 47:102293. [PMID: 35247581 DOI: 10.1016/j.tmaid.2022.102293] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
Travellers' diarrhoea (TD) is the most frequent illness experienced by international travellers to lower-income countries with bacterial agents considered to account for 80-90% of cases. In this review, we summarise evidence published on bacterial TD over the past 10 years, focusing on the epidemiology and aetiology of TD. Diarrhoeagenic Escherichia coli (DEC) continue to be the most commonly implicated bacteria in TD, although Enteropathogenic E. coli (EPEC) and Enteroaggregative E. coli (EAEC) now appear to be predominant where Enterotoxigenic E. coli (ETEC) was previously considered most prevalent globally. Where fluroquinolone resistance had primarily been documented for Campylobacter in Southeast Asia, widespread resistance has been observed in most regions of the world for multiple enteropathogens, including Shigella, Salmonella, ETEC and EAEC. Implementation of novel molecular methods for pathogen detection has led to identification of bacterial pathogens, including Clostridium difficile (with and without the use of prior antibiotics), Arcobacter species and Bacteroides fragilis, as aetiological agents in TD. The widespread resistance to first-line antibiotics in multiple bacterial enteropathogens warrants continued surveillance and re-evaluation of current treatment practices. Further investigations are required to determine the prevalence and geographical distribution of bacterial enteropathogens that have been more recently implicated in TD.
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Affiliation(s)
- Rogelio Lόpez-Vélez
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, IRYCIS, 28034, Madrid, Spain.
| | - Michael Lebens
- Department of Microbiology and Immunology, University of Gothenburg, Box 435, SE-40530, Gothenburg, Sweden.
| | - Leah Bundy
- Elements Communications Ltd, Westerham, TN16 1RQ, UK.
| | - Juan Barriga
- Department of Medical Affairs Europe, Emergent BioSolutions, 1455, Madrid, Spain.
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, World Health Organization Collaborating Centre for Travelers' Health, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland; Epidemiology, Human Genetics and Environmental Sciences Division, University of Texas School of Public Health, Houston, TX 77030, Texas, USA.
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Agbemavor WSK, Buys EM. Presumptive probiotic bacteria from traditionally fermented African food challenge the adhesion of enteroaggregative
E. coli
. J Food Saf 2021. [DOI: 10.1111/jfs.12905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Wisdom Selorm Kofi Agbemavor
- Department of Consumer and Food Sciences University of Pretoria Lynnwood Rd, Hatfield, Pretoria, 0002 South Africa
| | - Elna Maria Buys
- Department of Consumer and Food Sciences University of Pretoria Lynnwood Rd, Hatfield, Pretoria, 0002 South Africa
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Bacterial, viral and parasitic pathogens analysed by qPCR: Findings from a prospective study of travellers' diarrhoea. Travel Med Infect Dis 2020; 40:101957. [PMID: 33359433 DOI: 10.1016/j.tmaid.2020.101957] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The diagnostics of travellers' diarrhoea (TD) has been revolutionised by multiplex qPCR assays. While mostly of bacterial aetiology, viruses and parasites account for the disease among 10-20% of travellers. Despite this, prospective studies applying qPCR assays remain scarce that cover not only bacteria, such as the various diarrhoeagenic Escherichia coli (DEC), but also viral and parasitic pathogens. METHOD We analysed by qPCR pre- and post-travel stool samples of 146 Finnish travellers for bacterial, viral and parasitic pathogens: enteropathogenic (EPEC), enteroaggregative (EAEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC), and enteroinvasive (EIEC) E. coli; Shigella, Campylobacter, Salmonella, Yersinia and Vibrio cholerae; norovirus G1 and G2, rotavirus, enteroviruses, and sapovirus; and Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Symptoms and medication data during travel were collected by questionnaires. RESULTS We detected bacterial pathogens in 102/146 samples (69.9%; EAEC, EPEC, ETEC most common), viral ones in 13 (8.9%; norovirus most common), and parasitic ones in one (0.7%; Giardia). Noroviruses were associated with severe symptoms (23.5% versus non-severe 4.9%). In the TD group, 41.7% (5/12) of those with viral pathogens (vs. 13.3%; 11/83 without) took antibiotics. CONCLUSION Viral pathogens, particularly noroviruses, prevail in severe TD. The symptoms of viral disease are often severe and lead to unwarranted use of antibiotics.
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Wiemer D, Schwarz NG, Burchard GD, Frickmann H, Loderstaedt U, Hagen RM. Surveillance of enteropathogenic bacteria, protozoa and helminths in travellers returning from the tropics. Eur J Microbiol Immunol (Bp) 2020; 10:147-155. [PMID: 32910786 PMCID: PMC7592519 DOI: 10.1556/1886.2020.00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/11/2020] [Indexed: 11/19/2022] Open
Abstract
Diarrhoea is a frequent symptom associated with travelling to tropical regions, but the cause is often not found. Epidemiology was assessed including up-to-date real-time PCR approaches.We analysed datasets of 528 patients who presented at the Bernhard Nocht Institute for Tropical Medicine in Hamburg, Germany, between 2006 and 2010 for screening purposes or because of diarrhoea. Stool samples were obtained and investigated by microscopy, bacterial culture, two PCR assays targeting Entamoeba histolytica, Entamoeba dispar, Giardia duodenalis, and Cryptosporidium parvum, or Salmonella spp., Shigella/EIEC spp., Campylobacter jejuni, and Yersinia spp.Among patients with gastrointestinal symptoms, 51% tested positive for bacteria or parasites, of which 66% had a known enteropathogenic potential. In patients without diarrhoea, 53% (n = 80) were positive, and 33% of these cases harboured agents of pathogenic potential. Association with clinical symptoms was primarily found for bacterial infections. Blastocystis hominis, however, was more frequent in asymptomatic than in symptomatic travellers.In conclusion, the study stresses the etiological relevance of bacterial gastroenteritis in travellers returning from the tropics, the need for molecular approaches to increase diagnostic sensitivity and demonstrates that asymptomatic carriage of enteropathogens after prolonged stays in the tropics is similarly frequent compared with symptomatic infections in travellers.
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Affiliation(s)
- Dorothea Wiemer
- 1Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | | | | | - Hagen Frickmann
- 1Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany.,3Institute for Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | | | - Ralf-Matthias Hagen
- 4Department for Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
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Schaumburg F, Correa-Martinez CL, Niemann S, Köck R, Becker K. Aetiology of traveller's diarrhea: A nested case-control study. Travel Med Infect Dis 2020; 37:101696. [DOI: 10.1016/j.tmaid.2020.101696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/27/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
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Voor In 't Holt AF, Mourik K, Beishuizen B, van der Schoor AS, Verbon A, Vos MC, Severin JA. Acquisition of multidrug-resistant Enterobacterales during international travel: a systematic review of clinical and microbiological characteristics and meta-analyses of risk factors. Antimicrob Resist Infect Control 2020; 9:71. [PMID: 32434591 PMCID: PMC7237615 DOI: 10.1186/s13756-020-00733-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/09/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND International tourism increased from 25 million tourist arrivals in 1950 to over 1.3 billion in 2017. These travelers can be exposed to (multi) resistant microorganisms, may become colonized, and bring them back home. This systematic review aims to identify the carriage rates of multidrug-resistant Enterobacterales (MDR-E) among returning travelers, to identify microbiological methods used, and to identify the leading risk factors for acquiring MDR-E during international travel. METHODS Articles related to our research question were identified through a literature search in multiple databases (until June 18, 2019) - Embase, Medline Ovid, Cochrane, Scopus, Cinahl, Web of Science, and Google Scholar. RESULTS Out of 3211 potentially relevant articles, we included 22 studies in the systematic review, and 12 studies in 7 random-effects meta-analyses. Highest carriage rates of MDR-E were observed after travel to Southern Asia (median 71%), followed by travel to Northern Africa (median 42%). Carbapenemase-producing Enterobacterales (CPE) were identified in 5 out of 22 studies, from a few patients. However, in only eight out of 22 studies (36.4%) the initial laboratory method targeted detection of the presence of CPE in the original samples. The risk factor with the highest pooled odds ratio (OR) for MDR-E was travel to Southern Asia (pooled OR = 14.16, 95% confidence interval [CI] = 5.50 to 36.45), followed by antibiotic use during travel (pooled OR = 2.78, 95% CI = 1.76 to 4.39). CONCLUSIONS Risk of acquiring MDR-E while travelling increases depending on travel destination and if antibiotics are used during travel. This information is useful for the development of guidelines for healthcare facilities with low MDR-E prevalence rates to prevent admission of carriers without appropriate measures. The impact of such guidelines should be assessed.
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Affiliation(s)
- Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Kees Mourik
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Berend Beishuizen
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Adriënne S van der Schoor
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Annelies Verbon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Juliëtte A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
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Ashkenazi S, Schwartz E. Traveler's diarrhea in children: New insights and existing gaps. Travel Med Infect Dis 2019; 34:101503. [PMID: 31654742 DOI: 10.1016/j.tmaid.2019.101503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/15/2019] [Accepted: 10/21/2019] [Indexed: 01/17/2023]
Abstract
The number of children accompanying their parents in international travel is increasing steadily, and with the rising global migration, children more frequently accompany their parents or caregivers for visiting friends or relatives (VFR). As compared to travel for tourism, VFR children are at higher risk of acquiring local diseases, as they more often stay in rural areas in resource-poor locations, have longer periods of visit, are less likely to attend pre-travel consultations, and less frequently adhere to recommended precautions. Travelers's diarrhea (TD) is the most common travel-associated illnesses in children. This review updates the existing knowledge on TD in children, regarding its distinctive epidemiology, risk factors, preventive measures, clinical manifestations, complications, causative microorganisms and management. Despite the limited focused research on pediatric TD, which challenges the formulation of children-oriented evidence-based guidelines, practical recommendations are suggested.
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Affiliation(s)
- Shai Ashkenazi
- Adelson School of Medicine, Ariel University, Ariel, Israel; Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
| | - Eli Schwartz
- Center for Geographic Medicine and Tropical Diseases, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kuenzli E, Jaeger VK, DeCrom S, Sydow V, Muigg V, Frei R, Egli A, Fehr J, Hatz C. Impact of alcohol-based hand-gel sanitizer and hand hygiene advice on travellers' diarrhoea and colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae: A randomised, controlled trial. Travel Med Infect Dis 2019; 32:101475. [PMID: 31499238 DOI: 10.1016/j.tmaid.2019.101475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is the most common health problem in international travellers. Besides being bothersome for the individual and a considerable economic burden for the public, TD is also known to be associated with becoming colonized with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriacea. Despite the high frequency of TD cases, easy and effective preventive measures are lacking. The aim of this study was to assess the impact of using hand gel sanitizer on the incidence of TD and colonization with ESBL-producing Enterobacteriaceae. METHOD A multicentre randomized intervention trial studying the effect of hand gel sanitizer on the incidence of TD and colonization with ESBL-producing Enterobacteriaceae in travellers to Southeast Asia was performed. RESULTS The intention to treat analysis showed a reduction in the incidence of WHO TD in the intervention group (OR 0.54 (95% CI 0.30-0.97), p = 0.04). No effect was seen or the incidence of becoming colonized with ESBL-producing Enterobacteriaceae. CONCLUSION Using hand gel sanitizer might have a protective effect on the occurrence of TD. Based on the current data, education on the proper use appears to play a key role for its effectiveness.
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Affiliation(s)
- Esther Kuenzli
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Veronika K Jaeger
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland; Institute for Epidemiology and Social Medicine, University of Münster, Germany
| | - Susan DeCrom
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Véronique Sydow
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Veronika Muigg
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Reno Frei
- Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Adrian Egli
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Jan Fehr
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Hatz
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Infectious Diseases and Hospital Hygiene, Cantonal Hospital, St. Gallen, Switzerland
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Epidemiology and etiology of diarrhea in UK military personnel serving on the United Nations Mission in South Sudan in 2017: A prospective cohort study. Travel Med Infect Dis 2019; 28:34-40. [DOI: 10.1016/j.tmaid.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023]
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Lääveri T, Vilkman K, Pakkanen S, Kirveskari J, Kantele A. Despite antibiotic treatment of travellers' diarrhoea, pathogens are found in stools from half of travellers at return. Travel Med Infect Dis 2018; 23:49-55. [PMID: 29702254 DOI: 10.1016/j.tmaid.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/24/2018] [Accepted: 04/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Among visitors to the (sub)tropics, 20-50% contract travellers' diarrhoea (TD) and 5-30% take antibiotics. While shortening the duration of illness, antimicrobials predispose to acquisition of multi-drug resistant bacteria. Therefore, liberal use is no longer advocated. Although antibiotics kill pathogens, no data support the view that they could prevent post-infectious sequelae. We investigated how antibiotic use for TD abroad impacts the pathogen findings at return. MATERIALS AND METHODS We revisited 456 travellers' clinical data and stool pathogens examined by qPCR for Salmonella, Yersinia, Campylobacter, Shigella, Vibrio cholerae and enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC) and enteroinvasive (EIEC) Escherichia coli. RESULTS Among travellers with TD, antibiotic users had pathogen-positive samples less frequently than non-users (50% versus 83%). The difference was significant for EPEC (23% versus 47%) and EAEC (27% versus 54%), but not ETEC (17% versus 26%) or the other pathogens. Shigella/EIEC was found more often among antibiotic users than non-users (4% versus 1%). CONCLUSION Despite antibiotic treatment of TD, half of the users still had stool pathogens at return, reflecting either antibiotic resistance of pathogens or recolonisation/reinfection while abroad. Treatment of TD with antibiotics during travel should not be interpreted to indicate eradication of pathogens.
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Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland.
| | - Katri Vilkman
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland.
| | - Sari Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland, POB 21, FIN-00014 Helsinki, Finland.
| | - Juha Kirveskari
- Helsinki University Hospital Laboratory (HUSLAB), Department of Bacteriology, Helsinki, Finland, POB 720, FIN-00029 HUS, Finland; Mobidiag Ltd, Espoo, Finland, Keilaranta 16 A, FIN-02150 Espoo Finland.
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland; Clinicum, University of Helsinki, Helsinki, Finland, POB 63, FI-00014 Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland, Annankatu 32, FIN-00100 Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, Stockholm, Sweden, SE-17176 Stockholm, Sweden.
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