Spectrum of disease and relation to place of exposure among ill returned travelers

How to manage adult patients with malaria in the non-endemic setting

BACKGROUND

The diagnosis and management of malaria in non-endemic countries presents a continuing challenge. Plasmodium falciparum, which is capable of rapidly inducing severe and life-threatening multiorgan disease, is the species most frequently diagnosed in Europe and North America.

OBJECTIVES

To summarise the more relevant diagnostic findings and clinical features of malaria observed in non-endemic settings and to provide an update of the key management decision points using three illustrative clinical scenarios of uncomplicated and severe malaria.

SOURCES

The discussion is based on a relevant literature search spanning the last 20 years. Recommendations are based on available clinical guidelines including those of the WHO, observational studies conducted in non-endemic settings, and, when available, extrapolation from randomised studies from malaria-endemic settings.

CONTENT

The following topics are covered: diagnosis, including the use of molecular biology; clinical characteristics; management with a specific focus on complicated (severe) and uncomplicated malaria; and areas of resistance to available antimalarial drugs.

IMPLICATIONS

Malaria imported to non-endemic settings, especially P. falciparum malaria, is sometimes initially overlooked and the delayed diagnosis is responsible for every year of preventable deaths. This review aims to raise awareness of malaria outside endemic countries and to provide clinicians with a practical guide for efficient diagnosis and targeted therapy for the different species involved.

Intestinal protozoa in returning travellers: a GeoSentinel analysis from 2007 to 2019

BACKGROUND

Prolonged diarrhoea is common amongst returning travellers and is often caused by intestinal protozoa. However, the epidemiology of travel-associated illness caused by protozoal pathogens is not well described.

METHODS

We analysed records of returning international travellers with illness caused by Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis or Cystoisospora belli, reported to the GeoSentinel Network during January 2007-December 2019. We excluded records of travellers migrating, with an unascertainable exposure country, or from GeoSentinel sites that were not located in high-income countries.

RESULTS

There were 2517 cases, 82.3% giardiasis (n = 2072), 11.4% cryptosporidiosis (n = 287), 6.0% cyclosporiasis (n = 150) and 0.3% cystoisosporiasis (n = 8). Overall, most travellers were tourists (64.4%) on long trips (median durations: 18-30 days). Cryptosporidiosis more frequently affected people < 18 years (13.9%) and cyclosporiasis affected people ≥ 40 years (59.4%). Giardiasis was most frequently acquired in South Central Asia (45.8%) and sub-Saharan Africa (22.6%), cryptosporidiosis in sub-Saharan Africa (24.7%) and South-Central Asia (19.5%), cyclosporiasis in South East Asia (31.3%) and Central America (27.3%), and cystoisosporiasis in sub-Saharan Africa (62.5%). Cyclosporiasis cases were reported from countries of uncertain endemicity (e.g. Cambodia) or in countries with no previous evidence of this parasite (e.g. French Guiana). The time from symptom onset to presentation at a GeoSentinel site was the longest amongst travellers with giardiasis (median: 30 days). Over 14% of travellers with cryptosporidiosis were hospitalized.

CONCLUSIONS

This analysis provides new insights into the epidemiology and clinical significance of four intestinal protozoa that can cause morbidity in international travellers. These data might help optimize pretravel advice and post-travel management of patients with travel-associated prolonged gastrointestinal illnesses. This analysis reinforces the importance of international travel-related surveillance to identify sentinel cases and areas where protozoal infections might be undetected or underreported.

Yellow fever - An old foe with new developments

INTRODUCTION

Yellow fever is caused by an RNA flavivirus. Immunisation in conjunction with vector control is at the forefront of yellow fever control and elimination.

OBJECTIVE

This narrative review describes the impact and importance of yellow fever vaccinations for northern Australian health practitioners.

DESIGN

Selected key policies, studies and medical guidelines are reviewed and presented.

FINDING

Large yellow fever outbreaks, associated with vector spread, have occurred in the last decade in Africa and South America, increasing the risk of international spread of the virus. Mobile populations, like travellers or migrant workers, continue to be at risk of yellow fever. Quality assurance, including yellow fever centre accreditation and initiatives to decrease fraudulent yellow fever vaccination documentation, has evolved in the past few years. Fractional dosing of yellow fever vaccines has been shown to provide protection for 1 year in outbreak scenarios, but further studies are needed.

DISCUSSION

Although Australia is yellow fever-free, the disease could be introduced by viraemic persons as a competent Aedes mosquito vector is present in northern Australia. In addition to surveillance and vector control, health education and yellow fever vaccination remain the best lines of defence. In the event of an outbreak, a response via fractional dosing could prove to be effective in controlling the virus.

CONCLUSION

Health care providers in northern Australia should be aware of the risks of yellow fever and its introduction to northern Australia and be able to discuss vaccination status with their clients when needed.

Fever and Rash

Infectious causes of fever and rash pose a diagnostic challenge for the emergency provider. It is often difficult to discern rashes associated with rapidly progressive and life-threatening infections from benign exanthems, which comprise the majority of rashes seen in the emergency department. Physicians must also consider serious noninfectious causes of fever and rash. A correct diagnosis depends on an exhaustive history and head-to-toe skin examination as most emergent causes of fever and rash remain clinical diagnoses. A provisional diagnosis and immediate treatment with antimicrobials and supportive care are usually required prior to the return of confirmatory laboratory testing.

New insights into the systematics of the afrotropical Amblyomma marmoreum complex (Acari: Ixodidae) and the genome of a novel Rickettsia africae strain using morphological and metagenomic approaches

The Amblyomma marmoreum complex includes afrotropical species, such as Amblyomma sparsum, a three-host tick that parasitizes reptiles, birds, and mammals, and is a recognized vector of Ehrlichia ruminantium. However, the lack of morphological, genetic and ecological data on A. sparsum has caused considerable confusion in its identification. In this study, we used microscopy and metagenomic approaches to analyze A. sparsum ticks collected from a puff adder snake (Bitis arietans) in southwest Senegal (an endemic rickettsioses area) in order to supplement previous morphological descriptions, provide novel genomic data for the A. marmoreum complex, and describe the genome of a novel spotted fever group Rickettsia strain. Based on stereoscope and scanning electron microscopy (SEM) morphological evaluations, we provide high-quality images and new insights about punctation and enameling in the adult male of A. sparsum to facilitate identification for future studies. The metagenomic approach allowed us assembly the complete mitochondrial genome of A. sparsum, as well as the nearly entire chromosome and complete plasmid sequences of a novel Rickettsia africae strain. Phylogenomic analyses demonstrated a close relationship between A. sparsum and Amblyomma nuttalli for the first time and confirmed the position of A. sparsum within the A. marmoreum complex. Our results provide new insights into the systematics of A. sparsum and A. marmoreum complex, as well as the genetic diversity of R. africae in the Afrotropical region. Future studies should consider the possibility that A. sparsum may be a vector for R. africae.

Molecular Detection and Characterization of Rickettsia Species in Ixodid Ticks from Selected Regions of Namibia

Rickettsial pathogens are among the emerging and re-emerging vector-borne zoonoses of public health importance. Reports indicate human exposure to Rickettsial pathogens in Namibia through serological surveys, but there is a lack of data on infection rates in tick vectors, hindering the assessment of the relative risk to humans. Our study sought to screen Ixodid ticks collected from livestock for the presence of Rickettsia species in order to determine infection rates in ticks and to determine the Rickettsia species circulating in the country. We collected and pooled Hyalomma and Rhipicephalus ticks from two adjacent regions of Namibia (Khomas and Otjozondjupa) and observed an overall minimum Rickettsia infection rate of 8.6% (26/304), with an estimated overall pooled prevalence of 9.94% (95% CI: 6.5-14.3). There were no statistically significant differences in the estimated pooled prevalence between the two regions or tick genera. Based on the nucleotide sequence similarity and phylogenetic analysis of the outer membrane protein A (n = 9) and citrate synthase (n = 12) genes, BLAST analysis revealed similarity between Rickettsia africae (n = 2) and Rickettsia aeschlimannii (n = 11), with sequence identities ranging from 98.46 to 100%. Our initial study in Namibia indicates that both zoonotic R. africae and R. aeschlimannii are in circulation in the country, with R. aeschlimannii being the predominant species.

Serological detection of Rickettsia spp. and evaluation of blood parameters in pet dogs and cats from Bangkok and neighboring provinces

Rickettsiosis is caused by Orientia spp. and Rickettsia spp., arthropod-borne zoonotic intracellular bacteria. The close relationships between pet dogs, cats and owners increase the risk of rickettsial transmission, with limited studies on the seroprevalence in pets. This study investigated the prevalence of rickettsia exposure among dogs and cats in Bangkok and neighboring provinces. The samples from 367 dogs and 187 cats used in this study were leftover serum samples from routine laboratory testing stored at the Veterinary Teaching Hospital. In-house Enzyme-linked immunosorbent assay (ELISA) tests included IgG against the scrub typhus group (STG), typhus group (TG), and spotted fever group (SFG). The seroprevalence in pet dogs was 30.25% (111/367), including 21.53% for STG, 4.36% for TG, and 1.09% for SFG. Co-seroprevalence consisted of 2.72% for STG and TG, 0.27% for STG and SFG, and 0.27% for pangroup infection. The prevalence in cats was 62.56% (117/187), including 28.34% for STG, 4.28% for TG, and 6.42% for STG. Co-seroprevalence in cats consisted of STG and TG (4.28%), STG and SFG (5.35%), TG and SFG (3.21%), and three-group infection (10.69%). No significant difference in seroprevalence for the three serogroups was observed in any of the 64 districts sampled. The mean hematocrit level significantly decreased in seropositive dogs (P<0.05). Seropositive dogs and cats were detected in significantly greater numbers of anemia cases than nonanemia cases (P<0.05) (odds ratio: 7.93, 0.44, p = 0.00, p = 0.01). A significantly higher number of seropositive cats had decreased hemoglobin levels (P<0.05) (odds ratio: 3.63, p = 0.00). The seropositive samples significantly differed among older cats (P<0.05). These high exposures in pet dogs and cats could constitute important relationship dynamics between companion animals and rickettsial vectors. Significantly decreased hematocrit and hemoglobin levels indicated anemia in the exposed dogs and cats. The study findings will raise awareness of this neglected disease among pet owners and veterinary hospital personnel and aid in future public health preventative planning.

Extracellular Vesicles: A Novel Mode of Viral Propagation Exploited by Enveloped and Non-Enveloped Viruses

Extracellular vesicles (EVs) are small membrane-enclosed structures that have gained much attention from researchers across varying scientific fields in the past few decades. Cells secrete diverse types of EVs into the extracellular milieu which include exosomes, microvesicles, and apoptotic bodies. These EVs play a crucial role in facilitating intracellular communication via the transport of proteins, lipids, DNA, rRNA, and miRNAs. It is well known that a number of viruses hijack several cellular pathways involved in EV biogenesis to aid in their replication, assembly, and egress. On the other hand, EVs can also trigger host antiviral immune responses by carrying immunomodulatory molecules and viral antigens on their surface. Owing to this intricate relationship between EVs and viruses, intriguing studies have identified various EV-mediated viral infections and interrogated how EVs can alter overall viral spread and longevity. This review provides a comprehensive overview on the EV-virus relationship, and details various modes of EV-mediated viral spread in the context of clinically relevant enveloped and non-enveloped viruses.

Cutaneous larva migrans: A One Health Perspective on Familial Infection Among Tourists Returning from Southeast Asia

Cutaneous larva migrans (CLM) is a dermatosis caused by accidental infestation with animal hookworms and is widely distributed in tropical and subtropical regions. Humans become infected when their skin comes into contact with soil contaminated with dog faeces. The filariform larvae penetrate and burrow into human skin, causing a condition known as "creeping eruption". We describe a case, well-documented by photos, of CLM infection in a family of three who returned from Thailand.

Molecular detection of Rickettsia africae from Amblyomma hebraeum ticks in Mafikeng city of North West Province, South Africa

Rickettsia africae causes zoonotic African tick bite fever, which is a disease of "One Health" importance. There have been reported cases of tourists from Europe and Asia who have been bitten by ticks whilst visiting South Africa's nature reserves, and on their return to their countries, the display African Tick Bite Fever sickness. Hence, the aim of this study was to determine the occurrence of Rickettsia africae in Amblyomma hebraeum ticks infesting livestock in the North West Province. A total of 358 A. hebraeum ticks were collected from 60 ruminants (cattle, sheep and goats) in Mafikeng City of North West Province, South Africa. Ticks were identified morphologically and further confirmed by sequencing of their ITS2 gene. DNA was extracted from 60 pools of ticks which consisted of 5-6 adult ticks that were from the same ruminant host. Infections with Rickettsia spp. were found in 48%, 40%, and 32% of cattle, sheep, and goats, respectively, in amplification by PCR using the ompA gene. The ompA gene sequences showed that the Rickettsia spp. were identified as R. africae. Although the animals from whom the ticks were collected did not exhibit any clinical symptoms, it is well recognised that R. africae is a disease with significant zoonotic potential. Thus, it is important to use the "One Health" approach to formulate prevention and control measures for this pathogen for animal and human health as well as the tourism sector due to the ecotourism importance of the resultant disease.

Epidemiology of giardiasis and assemblages A and B and effects on diarrhea and growth trajectories during the first 8 years of life: Analysis of a birth cohort in a rural district in tropical Ecuador

BACKGROUND

There are limited longitudinal data on the acquisition of Giardia lamblia infections in childhood using molecular assays to detect and type assemblages, and measure effects of infections on diarrhea risk and childhood growth.

METHODS

We analysed stool samples from a surveillance sample within a birth cohort in a rural district in tropical Ecuador. The cohort was followed to 8 years of age for the presence of G. lamblia in stools by quantitative PCR and A and B assemblages by Taqman assay or Sanger sequencing. We explored risk factors associated with infection using generalized estimating equations applied to longitudinal binary outcomes, and longitudinal panel data analysis to estimate effects of infection on diarrhea and growth trajectories.

RESULTS

2,812 stool samples collected between 1 month and 8 years of age from 498 children were analyzed and showed high rates of infection: 79.7% were infected at least once with peak prevalence (53.9%) at 5 years. Assemblage B was accounted for 56.8% of genotyped infections. Risk factors for infection included male sex (P = 0.001), daycare attendance (P<0.001), having a household latrine (P = 0.04), childhood (P<0.001) and maternal soil-transmitted helminth (P = 0.029) infections, and exposures to donkeys (age interaction P = 0.034). G. lamblia was associated with increased risk of diarrhea (per episode, RR 1.03, 95% CI 1.01-1.06, P = 0.011) during the first 3 years of life and a transient impairment of weight (age interaction P = 0.017) and height-for-age (age interaction P = 0.025) trajectories between 1 and 4 years of age. There was no increased risk of either assemblage being associated with outcomes.

CONCLUSION

Our data show a relatively high edemicity of G. lamblia transmission during childhood in coastal Ecuador, and evidence that infection is associated with a transiently increased risk of diarrhea during the first 3 years of life and impairment of weight and height between 1 and 4 years.

Diarrhea don'ts: Reducing inappropriate stool cultures and ova and parasite testing for nosocomial diarrhea

BACKGROUND

Diarrhea that develops in patients after 72 hours of hospitalization is likely to have a nosocomial or iatrogenic etiology. Testing with stool cultures and stool ova and parasites (O&P) is not recommended. Our goal was to reduce this inappropriate testing within a large, urban safety-net hospital system.

METHODS

This was a quality improvement project. We created a best practice advisory (BPA) within the electronic medical record that fires when a stool culture or O&P order is placed 72 hours after admission for any immunocompetent patient. It states that stool testing is low yield and offers the option to remove the order. We measured weekly counts of stool culture and stool O&P orders pre- and postintervention. We also measured the BPA acceptance rate, the 24-hour stool testing reorder rate, and Clostridioides difficile infection rates. Data were analyzed using Welch tests as well as a quasi-experimental pre- and postintervention interrupted time series regression analysis.

RESULTS

Stool culture orders decreased by 24.4% (P < .001). There was a significant level difference and slope difference with linear regression. Five of the 11 hospitals had a significant reduction in stool culture orders. Stool O&P orders decreased by 18.2% (P < .01). Three of the 11 hospitals had a significant reduction in stool O&P orders.

CONCLUSIONS

Our intervention successfully reduced inappropriate stool testing within a large safety-net hospital system.

A malaria death due to an imported Plasmodium falciparum infection in Sri Lanka during the prevention of re-establishment phase of malaria

BACKGROUND

Sri Lanka has maintained a rigorous programme to prevent the re-establishment of malaria ever since the disease was eliminated in October 2012. It includes efforts to sustain case surveillance to ensure early diagnosis and management of malaria. Yet, in April of 2023 the death occurred of an individual with imported malaria.

CASE PRESENTATION

The deceased was a 37-year-old Sri Lankan male who returned to Sri Lanka on the 10th of April after a business trip to several countries including Tanzania. He was febrile on arrival and consulted three Allopathic Medical Practitioners in succession in his home town in the Western Province of Sri Lanka, over a period of 5 days starting from the very day that he arrived in the country. Malaria was not tested for at any of these consultations and his clinical condition deteriorated. On the evening of 14th of April he was admitted to the medical intensive care unit of a major private hospital in the capital city of Colombo with multiple organ failure. There, on a request by the treating physician blood was tested for malaria and reported early the next morning as Plasmodium falciparum malaria with a high parasitaemia (> 10%). The patient died shortly after on the 15th of April before any anti-malarial medication was administered. The deceased had been a frequent business traveller to Africa, but with no past history of malaria. He had not taken chemoprophylaxis for malaria on this or previous travels to Africa.

DISCUSSION

The patient's P. falciparum infection progressed rapidly over 5 days of arriving in Sri Lanka leading to severe malaria without being diagnosed, despite him seeking healthcare from three different Medical Practitioners. Finally, a diagnosis of malaria was made on admission to an intensive care unit; the patient died before anti-malarial medicines were administered.

CONCLUSIONS

This first death due to severe P. falciparum malaria reported in Sri Lanka after elimination of the disease was due to the delay in diagnosing malaria.

Profiles of travelers to intermediate-high health risk areas following the reopening of borders in the COVID-19 crisis: A clustering approach

BACKGROUND

The reactivation of international travel in 2021 has created a new scenario in which the profile of the traveler to medium-high health risk areas may well have changed. However, few studies have analyzed this new profile since the reopening of borders in that year.

METHODS

We designed an ad hoc questionnaire that was administered face-to-face by our medical team during appointments with 330 travelers in the second half of 2021. Information was collected on the following topics: sociodemographic and socioeconomic status; type of travel and previous travel experience; health status and risk perception (of COVID-19 and tropical infectious diseases). Using all features simultaneously, an unsupervised machine learning approach (k-means) is implemented to characterize groups of travelers. Pairwise chi-squared tests were performed to identify key features that showed statistically significant differences between clusters.

RESULTS

The travelers were clustered into seven groups. We associated the clusters with different intensities of perceived risk of acquiring COVID-19 and tropical infectious diseases on the trip. The perceived risk of both diseases was low in the group "middle or lower middle class young inexperienced male tourist" but high in the group "middle or lower middle-class young with children inexperienced business traveler".

CONCLUSIONS

Broadening our knowledge of the profiles of travelers to intermediate-high health risk areas would help to tailor the health advice provided by practitioners to their characteristics and type of travel. In a changing health context, the k-means approach supposes a flexible statistical method that calculates travelers' profiles and can be easily adapted to process new information.

Morbidity of Returning Travelers Seen in Community Urgent Care Centers throughout Israel

Information regarding post-travel morbidity is usually reported via dedicated post-travel clinics and mainly relates to travelers returning from low-middle-income countries (LMIC), however, the spectrum of morbidity seen within the community setting is scarcely reported. This prospective observational study among visitors to 17 community Urgent Care Centers (UCC) was designed to evaluate the reasons for post-travel community clinic visits and to compare travelers returning from LMIC to high-income countries (HIC). All visitors within one-month post-travel to all destinations were included. A total of 1580 post-travel visits were analyzed during 25 months. Travelers to LMICs were younger (mean 36.8 years old vs. 41.4 in the HIC group) and stayed longer periods abroad (30.1 ± 41.2 vs. 10.0 ± 10.6 in the HIC group) but more of them had pre-travel vaccines (35.5% vs. 6.6%). Travel-related morbidity was significantly more common in the LMIC group 58.3% (253/434) vs. 34.1% (391/1146) in the HIC group, (p < 0.001). Acute diarrhea was the leading cause of morbidity after visiting LMIC (28.8%) and was significantly more common than in the HIC (6.6%, p < 0.001). Other common morbidities in the LMIC cohort were respiratory (23.3%), cutaneous (15.8%), and injuries (9.9%). In the HIC group, the common morbidities were respiratory (37.3%), and diarrhea composed only 6.6% of the complaints. Our study group represents a less biased sample of travelers to LMIC as well as HIC, therefore, data from the UCC setting and at the specialized travel clinics complete each other in understanding the true extent of morbidity in travelers.

Flaviviruses and the Traveler: Around the World and to Your Stage. A Review of West Nile, Yellow Fever, Dengue, and Zika Viruses for the Practicing Pathologist

Flaviviruses are a genus of single-stranded RNA viruses that impose an important and growing burden to human health. There are over 3 billion individuals living in areas where flaviviruses are endemic. Flaviviruses and their arthropod vectors (which include mosquitoes and ticks) take advantage of global travel to expand their distribution and cause severe disease in humans, and they can be grouped according to their vector and pathogenicity. The mosquito-borne flaviviruses cause a spectrum of diseases from encephalitis to hepatitis and vascular shock syndrome, congenital abnormalities, and fetal death. Neurotropic infections such as Zika virus and West Nile virus cross the blood-brain barrier and infect neurons and other cells, leading to meningoencephalitis. In the hemorrhagic fever clade, there are yellow fever virus, the prototypical hemorrhagic fever virus that infects hepatocytes, and dengue virus, which infects cells of the reticuloendothelial system and can lead to a dramatic plasma cell leakage and shock syndrome. Zika virus also causes congenital infections and fetal death and is the first and only example of a teratogenic arbovirus in humans. Diagnostic testing for flaviviruses broadly includes the detection of viral RNA in serum (particularly within the first 10 days of symptoms), viral isolation by cell culture (rarely performed due to complexity and biosafety concerns), and histopathologic evaluation with immunohistochemistry and molecular testing on formalin-fixed paraffin-embedded tissue blocks. This review focuses on 4 mosquito-borne flaviviruses-West Nile, yellow fever, dengue, and Zika virus-and discusses the mechanisms of transmission, the role of travel in geographic distribution and epidemic emergence, and the clinical and histopathologic features of each. Finally, prevention strategies such as vector control and vaccination are discussed.

Distribution and Prevalence of Anaplasmataceae, Rickettsiaceae and Coxiellaceae in African Ticks: A Systematic Review and Meta-Analysis

In Africa, ticks continue to be a major hindrance to the improvement of the livestock industry due to tick-borne pathogens that include Anaplasma, Ehrlichia, Rickettsia and Coxiella species. A systemic review and meta-analysis were conducted here and highlighted the distribution and prevalence of these tick-borne pathogens in African ticks. Relevant publications were searched in five electronic databases and selected using inclusion/exclusion criteria, resulting in 138 and 78 papers included in the qualitative and quantitative analysis, respectively. Most of the studies focused on Rickettsia africae (38 studies), followed by Ehrlichia ruminantium (27 studies), Coxiella burnetii (20 studies) and Anaplasma marginale (17 studies). A meta-analysis of proportions was performed using the random-effects model. The highest prevalence was obtained for Rickettsia spp. (18.39%; 95% CI: 14.23–22.85%), R. africae (13.47%; 95% CI: 2.76–28.69%), R. conorii (11.28%; 95% CI: 1.77–25.89%), A. marginale (12.75%; 95% CI: 4.06–24.35%), E. ruminantium (6.37%; 95% CI: 3.97–9.16%) and E. canis (4.3%; 95% CI: 0.04–12.66%). The prevalence of C. burnetii was low (0%; 95% CI: 0–0.25%), with higher prevalence for Coxiella spp. (27.02%; 95% CI: 10.83–46.03%) and Coxiella-like endosymbionts (70.47%; 95% CI: 27–99.82%). The effect of the tick genera, tick species, country and other variables were identified and highlighted the epidemiology of Rhipicephalus ticks in the heartwater; affinity of each Rickettsia species for different tick genera; dominant distribution of A. marginale, R. africae and Coxiella-like endosymbionts in ticks and a low distribution of C. burnetii in African hard ticks.

Imported diseases in travellers presenting to the emergency department after a stay in a malaria-endemic country: a retrospective observational study

BACKGROUND

We aimed to investigate the aetiology and outcomes of illnesses in patients presenting to an emergency department after travelling to a malaria-endemic country, in order to raise awareness of both tropical and cosmopolitan diseases.

METHODS

A retrospective chart review was performed for all patients who underwent blood smear testing for malaria at the Emergency Department of the University Hospitals Leuven from 2017 to 2020. Patient characteristics, results of laboratory and radiological examinations, diagnoses, disease course and outcome were collected and analysed.

RESULTS

A total of 253 patients were included in the study. The majority of ill travellers returned from Sub-Saharan Africa (68.4%) and Southeast Asia (19.4%). Their diagnoses fell into three major syndrome categories: systemic febrile illness (30.8%), inflammatory syndrome of unknown origin (23.3%) and acute diarrhoea (18.2%). Malaria (15.8%) was the most common specific diagnosis in patients with systemic febrile illness, followed by influenza (5.1%), rickettsiosis (3.2%), dengue (1.6%), enteric fever (0.8%), chikungunya (0.8%) and leptospirosis (0.8%). The presence of hyperbilirubinemia and thrombocytopenia increased the probability of malaria, with a likelihood ratio of 4.01 and 6.03, respectively. Seven patients (2.8%) were treated in the intensive care unit, and none died.

CONCLUSION

Systemic febrile illness, inflammatory syndrome of unknown origin and acute diarrhoea were the three major syndromic categories in returning travellers presenting to our emergency department after a stay in a malaria-endemic country. Malaria was the most common specific diagnosis in patients with systemic febrile illness. None of the patients died.

Cross-platform mobile app development for disseminating public health information to travelers in Thailand: development and usability

Background

The risk of disease is a key factor that travelers have identified when planning to travel abroad, as many people are concerned about getting sick. Mobile devices can be an effective means for travelers to access information regarding disease prevalence in their planned destinations, potentially reducing the risk of exposure.

Methods

We developed a mobile app, ThaiEpidemics, using cross-platform technology to provide information about disease prevalence and status for travelers to Thailand. We aimed to assess the app’s usability in terms of engagement, search logs, and effectiveness among target users. The app was developed using the principle of mobile application development life cycle, for both iOS and Android. As its data source, the app used weekly data from national disease-surveillance reports. We conduced our study among visitors to the Travel Clinic in the Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. The participants were informed that the app would collect usage and search logs related to their queries. After the second log-in, the app prompted participants to complete an e-survey regarding their opinions and preferences related to their awareness of disease prevalence and status.

Results

We based our prototype of ThaiEpidemics on a conceptualized framework for visualizing the distribution of 14 major diseases of concern to tourists in Southeast Asia. The app provided users with functions and features to search for and visualize disease prevalence and status in Thailand. The participants could access information for their current location and elsewhere in the country. In all, 83 people installed the app, and 52 responded to the e-survey. Regardless of age, education, and continent of origin, almost all e-survey respondents believed the app had raised their awareness of disease prevalence and status when travelling. Most participants searched for information for all 14 diseases; some searched for information specifically about dengue and malaria.

Conclusions

ThaiEpidemics is evidently potentially useful for travelers. Should the app be adopted for use by travelers to Thailand, it could have an impact on wider knowledge distribution, which might result in decreased exposure, increased prophylaxis, and therefore a potential decreased burden on the healthcare system. For app developers who are developing/implementing this kind of app, it is important to address standardization of the data source and users’ concerns about the confidentiality and safety of their mobile devices.

Incidence Rate and Risk Factors Associated with Travelers' Diarrhea in International Travelers Departing from Utah, USA

Despite knowledge on the causes and prevention strategies for travelers' diarrhea (TD), it continues to be one of the most common illnesses experienced by U.S. international travelers. However, studies of risk factors associated with TD among U.S. travelers are limited. In this study, we aimed to determine the incidence rate of TD, the proportion of travelers who experience TD, and to identify risk factors associated with TD. In this cross-sectional study, we collected and analyzed data from anonymous posttravel questionnaires submitted by international travelers recruited during their pretravel visit at two travel clinics in Salt Lake City, Utah, from October 2016 to March 2020. Of 571 travelers who completed posttravel surveys, 484 (85%) answered the TD question, of which 111 (23%) reported TD, for an incidence rate of 1.1 episodes per 100 travel-days (95% confidence interval [CI]: 0.9-1.4). In a multivariable model, visiting Southeast Asian (odds ratio [OR]: 2.60; 95% CI: 1.45-4.72) and African (OR: 2.06; 95% CI: 1.09-3.93]) WHO regions, having 10 or more individuals in the group (OR: 3.91; 95% CI: 1.50-11.32]), longer trip duration (OR: 1.01; 95% CI: 1.00-1.02), visiting both urban and rural destinations (OR: 1.94; 95% CI: 1.01-3.90), and taking medications/supplements to prevent TD (OR: 2.74; 95% CI: 1.69-4.47) were statistically significantly associated with increased odds of reporting TD. TD continues to be common in international travelers from the United States. Our findings provide insights regarding travelers' behaviors regarding TD in international travelers from high-income countries and shows the need for additional research into prevention strategies for travelers' diarrhea.

Isobaric tags for relative and absolute quantification-based proteomic analysis of host-pathogen protein interactions in the midgut of Aedes albopictus during dengue virus infection

Aedes albopictus (Ae. albopictus), an important vector of dengue virus (DENV), is distributed worldwide. Identifying host proteins involved in flavivirus replication in Ae. albopictus and determining their natural antiviral mechanisms are critical to control virus transmission. Revealing the key proteins related to virus replication and exploring the host-pathogen interaction are of great significance in finding new pathways of the natural immune response in Ae. albopictus. Isobaric tags for relative and absolute quantification (iTRAQ) was used to perform a comparative proteomic analysis between the midgut of Ae. albopictus infected with DENV and the control. 3,419 proteins were detected, of which 162 were ≥ 1.2-fold differentially upregulated or ≤ 0.8-fold differentially downregulated (p &lt; 0.05) during DENV infections. Differentially expressed proteins (DEPs) were mainly enriched in ubiquitin ligase complex, structural constituent of cuticle, carbohydrate metabolism, and lipid metabolism pathways. We found that one of the DEPs, a putative pupal cuticle (PC) protein could inhibit the replication of DENV and interact with the DENV-E protein. In addition, the result of immunofluorescence (IF) test showed that there was co-localization between ubiquitin carboxyl-terminal hydrolase (UCH) protein and the DENV-E protein, and virus infection reduced the level of this protein. iTRAQ-based proteomic analysis of the Ae. albopictus midgut identified dengue infection-induced upregulated and downregulated proteins. The interaction between the PC and UCH proteins in the midgut of Ae. albopictus might exert a natural antiviral mechanism in mosquito.

Unraveling the epidemiological relationship between ticks and rickettsial infection in Africa

Tick-borne rickettsioses are emerging and re-emerging diseases of public health concern caused by over 30 species of Rickettsia. Ticks are obligate hematophagous arthropods with over 700 species of Ixodid ticks known worldwide. The escalating geographical dispersal of tick vectors and concomitant increase in the incidences of tick-borne diseases have fueled interest in the ecology of tick-borne pathogens. This review focuses on aspects of the Rickettsia pathogen, including biology, taxonomy, phylogeny, genetic diversity, epidemiology of the disease, and the role of vertebrate host in the perpetuation of rickettsioses in Africa. Our review also highlights some of the species of Rickettsia that are responsible for disease, the role of tick vectors (both hard and soft ticks) and the species of Rickettsia associated with diverse tick species across the continent. Additionally, this article emphasizes the evolutionary perspective of rickettsiae perpetuation and the possible role of amplifying vertebrate host and other small mammals, domestic animals and wildlife in the epidemiology of Rickettsia species. We also specifically, discussed the role of avian population in the epidemiology of SFG rickettsiae. Furthermore, we highlighted tick-borne rickettsioses among travelers due to African tick-bite fever (ATBF) and the challenges to surveillance of rickettsial infection, and research on rickettsiology in Africa. Our review canvasses the need for more rickettsiologists of African origin based within the continent to further research towards understanding the biology, characterization, and species distribution, including the competent tick vectors involved in their transmission of rickettsiae across the continent in collaboration with established researchers in western countries. We further highlighted the need for proper funding to encourage research despite competing demands for resources across the various sectors. We finalize by discussing the similarities between rickettsial diseases around the world and which steps need to be taken to help foster our understanding on the eco-epidemiology of rickettsioses by bridging the gap between the growing epidemiological data and the molecular characterization of Rickettsia species.

Persistent abdominal symptoms in returning travellers: clinical and molecular findings

BACKGROUND

Persistent abdominal symptoms (PAS) are the leading cause of post-travel morbidity although there is a paucity of evidence concerning the aetiology of this condition. Recently molecular methods for protozoa detection in stool have been introduced. Herein, we describe the clinical aspects and the prevalence of gastrointestinal protozoa in returning travellers with PAS.

METHODS

From 2017 to 2019, clinical information and stool specimens from returning travellers with PAS were analysed for the presence of parasites using the Allplex-GI-Parasite-assay. Stool findings from symptomatic patients without a travel history were used as a comparator.

RESULTS

During the 2-year study, 203 stool specimens from returning travellers were analysed. The median duration of symptoms before seeking care was 6 months, the most common symptoms were fatigue (79.2%), abdominal pain (75.7%) and loose stool (70.8%).Most of travellers had returned from Asia (57.6%), mainly from the Indian-subcontinent and only 52.6% were backpackers. Altogether, 36.9% samples were positive for protozoa, with Blastocystis hominis being the most common (26.6%) in samples, followed by Dientamoeba fragilis (18.7%), Giardia lamblia (3.0%) and Cryptosporidium spp (0.5%). The former two were dominant in all regions. In all cases but one, G. lamblia was acquired, but one were acquired in the Indian subcontinent (odds ratios 16.9; 95% confidence intervals: 1.9-148.3). Entamoeba histolytica was not detected. The demographic characterization of the 1359 non-travellers was comparable with the travellers. Among them D. fragilis was the most common followed by B. hominis, which was significantly less frequent compared among the travellers (16.7% vs 26.6%, P < 0.001). Average Cycle threshold values for each stool parasites were comparable between the two groups.

CONCLUSION

Among returning travellers with PAS, more than one-third were positive for gastrointestinal protozoa. A low rate of giardia was found and no E. histolytica while B. hominis followed by D. fragilis were the dominant findings. Further studies are required to better understand the role of these protozoa in PAS.

Weather variables as important clinical predictors of bacterial diarrhoea among international travellers

BACKGROUND

Clinicians and travellers often have limited tools to differentiate bacterial from non-bacterial causes of travellers' diarrhoea (TD). Development of a clinical prediction rule assessing the aetiology of TD may help identify episodes of bacterial diarrhoea and limit inappropriate antibiotic use. We aimed to identify predictors of bacterial diarrhoea among clinical, demographic and weather variables, as well as to develop and cross-validate a parsimonious predictive model.

METHODS

We collected de-identified clinical data from 457 international travellers with acute diarrhoea presenting to two healthcare centres in Nepal and Thailand. We used conventional microbiologic and multiplex molecular methods to identify diarrheal aetiology from stool samples. We used random forest and logistic regression to determine predictors of bacterial diarrhoea.

RESULTS

We identified 195 cases of bacterial aetiology, 63 viral, 125 mixed pathogens, 6 protozoal/parasite and 68 cases without a detected pathogen. Random forest regression indicated that the strongest predictors of bacterial over viral or non-detected aetiologies were average location-specific environmental temperature and red blood cell on stool microscopy. In 5-fold cross-validation, the parsimonious model with the highest discriminative performance had an area under the receiver operator curve of 0.73 using 3 variables with calibration intercept -0.01 (standard deviation, SD 0.31) and slope 0.95 (SD 0.36).

CONCLUSIONS

We identified environmental temperature, a location-specific parameter, as an important predictor of bacterial TD, among traditional patient-specific parameters predictive of aetiology. Future work includes further validation and the development of a clinical decision-support tool to inform appropriate use of antibiotics in TD.

Entomological risk of African tick-bite fever (Rickettsia africae infection) in Eswatini

BACKGROUND

Rickettsia africae is a tick-borne bacterium that causes African tick-bite fever (ATBF) in humans. In southern Africa, the tick Amblyomma hebraeum serves as the primary vector and reservoir for R. africae and transmits the bacterium during any life stage. Previous research has shown that even when malaria has been dramatically reduced, unexplained acute febrile illnesses persist and may be explained by the serological evidence of rickettsiae in humans.

METHODOLOGY/PRINCIPAL FINDINGS

We collected 12,711 questing Amblyomma larvae across multiple land use types in a savanna landscape in Eswatini. Our results show that host-seeking Amblyomma larvae are abundant across both space and time, with no significant difference in density by land use or season. We investigated the entomological risk (density of infected larvae) of ATBF from A. hebraeum larvae by testing over 1,600 individual larvae for the presence of R. africae using a novel multiplex qPCR assay. We found an infection prevalence of 64.9% (95% CI: 62.1-67.6%) with no land use type significantly impacting prevalence during the dry season of 2018. The mean density of infected larvae was 57.3 individuals per 100m2 (95% CI: 49-65 individuals per 100m2).

CONCLUSIONS

Collectively, our results demonstrate R. africae infected A. hebraeum larvae, the most common tick species and life stage to bite humans in southern Africa, are ubiquitous in the savanna landscape of this region. Increased awareness of rickettsial diseases is warranted for policymakers, scientists, clinicians, and patients. Early detection of disease via increased clinician awareness and rapid diagnostics will improve patient outcomes for travelers and residents of this region.

Epidemiological characteristics of imported respiratory infectious diseases in China, 2014‒2018

Background

With the progress of globalization, international mobility increases, greatly facilitating cross-border transmission of respiratory infectious diseases (RIDs). This study aimed to analyze the epidemiological characteristics and factors influencing imported RIDs, with the goal of providing evidence to support adoption of high-tech, intelligent methods to early find imported RIDs and prevent their spread in China.

Methods

We obtained data of imported RIDs cases from 2014 to 2018 from the Inbound Sentinel Network of Customs and the National Notifiable Diseases Reporting System in China. We analyzed spatial, temporal, and population distribution characteristics of the imported RIDs. We developed an index to describe seasonality. Pearson correlation coefficients were used to examine associations between independent variables and imported cases. Data analyses and visualizations were conducted with R software.

Results

From a total of 1 409 265 253 inbound travelers, 31 732 (2.25/100 000) imported RIDs cases were reported. RIDs cases were imported from 142 countries and five continents. The incidence of imported RIDs was nearly 5 times higher in 2018 (2.81/100 000) than in 2014 (0.58/100 000). Among foreigners, incidence rates were higher among males (5.32/100 000), 0–14-year-olds (15.15/100 000), and cases originating in Oceania (11.10/100 000). The vast majority (90.3%) of imported RIDs were influenza, with seasonality consistent with annual seasonality of influenza. The spatial distribution of imported RIDs was different between Chinese citizens and foreigners. Increases in inbound travel volume and the number of influenza cases in source countries were associated with the number of imported RIDs.

Conclusions

Our study documented importation of RIDs into China from 142 countries. Inbound travel poses a significant risks bringing important RIDs to China. It is urgent to strengthen surveillance at customs of inbound travelers and establish an intelligent surveillance and early warning system to prevent importation of RIDs to China for preventing further spread within China.

Graphical Abstract

[CME: Fever in Travelers Returning from the Tropics]

CME: Fever in Travelers Returning from the Tropics Abstract. With rising numbers of travelers to tropic countries consultations for suspected tropical infections are on the rise in primary care and emergency units. The aim is to identify potentially life-threatening and highly contagious infectious diseases. In addition, counseling on the prevention of tropical diseases is taking on an important role. This article intends to provide an overview of the most important infections acquired in the tropics and support for clinical practice.

Rickettsiosis in Southeast Asia: Summary for International Travellers during the COVID-19 Pandemic

Rickettsiosis is an important cause of febrile illness among travellers visiting Southeast Asia (SEA). The true incidence of rickettsiosis is underestimated; however, murine typhus and scrub typhus are widely distributed across SEA. Among travellers visiting SEA, scrub typhus was mostly reported from Thailand, whereas murine typhus was frequently found in Indonesia. Although most cases are self-limited or present with mild symptoms, a few cases with severe clinical manifestations have been reported. Doxycycline remains the key treatment of rickettsiosis. Some travellers, such as backpackers, trekkers, or cave explorers, are at a higher risk for rickettsiosis than others. Therefore, in resource-limited conditions, empirical treatment should be considered in these travellers. The coronavirus disease 2019 (COVID-19) pandemic has contributed to difficulty in the diagnosis of rickettsiosis because of the clinical similarities between these diseases. In addition, physical distancing mandated by COVID-19 management guidelines limits accurate physical examination, resulting in misdiagnosis and delayed treatment of rickettsiosis. This review summarises the characteristics of murine typhus and scrub typhus, describes travel-associated rickettsiosis, and discusses the impact of the COVID-19 pandemic on rickettsiosis.

Etiology and outcome of febrile children coming from the tropics

INTRODUCTION

International travelers have grown significantly over last years, as well as imported diseases from tropical areas. Information in pediatric population is scarce. We describe demographic and clinical characteristics of febrile children coming from the tropics.

METHODS

Retrospective review of patients under 18 years old, presenting at a tertiary hospital and surrounding primary health care centers between July 2002 and July 2018 with a stay in a tropical region during the previous year. Patients were selected from microbiological charts of thick smears for malaria or dengue serologies.

RESULTS

188 patients were studied: 52.7% were born in Spain with a median age of 3.0 years old (IQR 1.5-8.0). Main regions of stay were Sub-Saharan Africa (54.8%) and Latin America (29.8%), mostly for visiting their friends and relatives (56.3%), followed by recent arrival migrants (32.4%). Only 34% of travelers attended pre-travel consultation. More than 80% of these febrile children attended directly the Emergency Room. The most frequent diagnoses were febrile syndrome without source (56.4%), respiratory condition (15.4%) and acute diarrhea (11.7%). Around a half (52.1%) were managed as outpatients, but 46.2% were hospitalized and 7.4% were admitted to Intensive Care Unit. No specific diagnosis was achieved in 24% of cases. However, 29.7% were diagnosed with malaria.

CONCLUSION

Children with fever coming from tropical areas were at risk of severe infectious diseases. Malaria was diagnosed in one out of four and 7% required admission in PICU. This information emphasizes the need of reinforcing training about tropical diseases among first line physicians.

Internationally Acquired Severe Systemic Infections in Febrile Pediatric Travelers Presenting to the Emergency Department

OBJECTIVES

Most children in the United States who visit the emergency department (ED) with fever have minor illnesses not requiring treatment or hospitalization. However, when a child has recently immigrated or traveled abroad, internationally acquired severe systemic infections (ISSIs) must be considered. We sought to describe children who have traveled internationally and present to the ED with a complaint of fever and to determine risk factors associated with ISSIs in these patients.

METHODS

We conducted a retrospective study of children younger than 18 years who presented to 2 pediatric EDs in Bronx, NY (June 2007 to May 2017). Patients were included if they had both fever within 24 hours and international travel within 30 days. We compared groups using bivariate analyses and created a prediction model for ISSIs using multivariable logistic regression.

RESULTS

Of the 353 children included, 44 (12%) had ISSI: 25 (57%), malaria; 6 (14%), dengue; and 13 (30%), bacteremia. Eight (18%) of those with ISSI presented with fever to another medical provider in the week prior but did not receive bloodwork. Four variables were independently associated with ISSIs: headache (odds ratio [OR], 21.7; 95% confidence interval [CI], 6.8-69.3), travel to Africa or Asia (OR, 18.8; 95% CI, 4.8-73.2), platelets of 150,000/μL or less (OR, 15.1; 95% CI, 4.7-48.6), and alanine aminotransferase level of 30 IU/L or greater (OR, 8.9; 95% CI, 3.1-25.3).

CONCLUSIONS

Children who travel internationally and present with fever upon return are at substantial risk for developing ISSIs. The diagnosis of ISSIs is often overlooked, but certain risk factors have the potential to aid clinicians.

Global dengue importation: a systematic review

Background

Importation of dengue following globalization presents an emerging threat to global health. However, evidence on global geographical sources and the potential of dengue importation globally are lacking. This study aims to systematically review the sources of dengue importation globally and the risk of dengue outbreaks globally.

Methods

This systematic review was conducted in accordance to Cochrane’s PRISMA guidelines. Articles published through 31 December 2019 with laboratory-confirmed dengue imported cases were consolidated from PubMed, EMBASE and Scopus. Sources of dengue importation reported worldwide were analysed by country and geographical regions. Sources of dengue importation into United States of America and Europe specifically were also analysed.

Results

A total of 3762 articles were found. Among which, 210 articles—documenting 14,972 imported dengue cases with reported sources—were eligible. 76.3% of imported cases worldwide were from Asia. 15.7%, 5.6%, 2.0% and 0.1% were imported from the Americas, Africa, Oceania and Europe regions respectively. Imported dengue cases in the U.S. were from Americas (55.3%), Asia (34.7%), Africa (6.7%) and Oceania (3.3%). Imported dengue cases in Europe were from Asia (66.0%), Americas (21.9%), Africa (10.8%) and Oceania (1.1%).

Conclusion

The potential of dengue outbreaks occurring globally, especially among non-endemic regions with dengue-susceptible populations is high. With the expansion of Aedes mosquito population globally due to global warming and globalisation, dengue importation constitutes an emerging global health security threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06740-1.

Risk of Trypanosoma cruzi infection among travellers visiting friends and relatives to continental Latin America

BACKGROUND

Chagas disease (CD) is regarded as a possible risk for travellers to endemic areas of continental Latin America (LA). The aim of the study is to determine the risk of Trypanosoma cruzi (TC) infection among travellers to CD endemic areas and to identify risk factors for acquiring TC infection.

METHODS/PRINCIPAL FINDING

We designed a multicenter cross-sectional study among travellers in Spain (Badalona, Barcelona and Madrid). All available adults with laboratory confirmed proof of absence of TC infection from January 2012 to December 2015 were contacted. Participants referring a trip to LA after the negative TC screening were offered to participate. We performed a standardized questionnaire of travel related factors and measurement of TC antibodies in serum. A total of 971 participants with baseline negative TC serology were selected from the microbiology records. After excluding participants not meeting inclusion criteria, eighty participants were selected. Sixty three (78.8%) were female, and the median age was 38 (IQR 34-47) years. The reason to travel was visiting friends and relatives in 98.8% of the participants. The median duration of travel was 40 (IQR 30-60) days, with 4911 participants-day of exposure. Seventy seven cases (96.25%) participants had two negative TC serology tests after the travel, two cases (2.5%) had discordant serology results (considered false positive results) and one case was infected before travelling to LA. According to our data, the upper limit of the 95% confidence interval of the incidence rate of TC acquisition in travellers is 0.8 per 1000 participant-days.

CONCLUSIONS/SIGNIFICANCE

Among 79 non-CD travellers to TC endemic areas, we found no cases of newly acquired TC infection. The incidence rate of TC acquisition in travellers to endemic countries is less than or equal to 0.8 per 1000 traveller-days.

Immunogenicity and safety of a tetravalent dengue vaccine in dengue-naïve adolescents in Mexico City

Objective.

To describe the immunogenicity and safety of a tetravalent dengue vaccine (TAK-003) in healthy adolescents living in Mexico City, an area considered non-endemic for dengue (NCT03341637).

Methods.

Participants aged 12–17 years were randomized 3:1 to receive two doses (Month 0 and Month 3) of TAK-003 or placebo. Immunogenicity was assessed by microneutralization assay of dengue neutralizing antibodies at baseline, Months 4 and 9. Solicited and unsolicited adverse events (AEs) were recorded after each vaccination. Serious (SAEs) and medically-attended AEs (MAAEs) were recorded throughout the study.

Results.

400 adolescents were enrolled, 391 (97.8%) completed the study. Thirty-six (9%) were baseline seropositive to ≥1 serotypes (reciprocal titer ≥10). Geometric mean titers (GMTs) in baseline seronegative TAK-003 recipients were 328, 1743, 120, and 143 at Month 4, and 135, 741, 46, and 38 at Month 9 against DENV-1, -2, -3, and -4, respectively. Placebo GMTs remained <10. Tetravalent seropositivity rates in vaccine recipients were 99.6% and 85.8% at Months 4 and 9, respectively. One MAAE in each group was considered treatment-related (TAK-003: injection-site erythema, and placebo: pharyngitis).

Conclusion.

TAK-003 was immunogenic against all four serotypes and was well tolerated in dengue-naïve adolescents living in Mexico City.

Risk factors for and management of metronidazole-refractory giardiasis in international travellers: A retrospective analysis

BACKGROUND

Giardia lamblia is a common cause of diarrhoea in returning travellers. Failure of the recommended first-line treatment, metronidazole, has frequently been observed. Recommendations for treatment of metronidazole-refractory giardiasis lack clarity and evidence.

METHODS

We conducted a retrospective data analysis of returned travellers with confirmed giardiasis at the Bernhard-Nocht-Clinic in Hamburg, Germany, between 2007 and 2016.

RESULTS

We identified 339 cases of giardiasis, mostly acquired in South Asia (n = 157). 308 patients received metronidazole as first-line treatment, leading to treatment failure in 93 cases. Statistical analysis suggested by far the highest risk of metronidazole treatment failure for travellers returning from South Asia (Odds Ratio 8.73). Second-line therapy consisted of various different therapy regimens. Combination therapy as second-line treatment seemed to be more effective than monotherapy. A repeat course of metronidazole proved to be futile.

CONCLUSION

This study reveals a strikingly low effectiveness of metronidazole, especially in patients returning from South Asia. Second-line treatment showed inconsistency of regimens and yielded unsatisfactory results. These findings require reconsideration of treatment strategies for giardiasis. Large prospective trials are urgently needed to assess new first-line treatment options and to help implement advice for effective, agreed second-line treatment strategies. Translational projects should be created to link the understanding of resistance mechanisms with epidemiological data and clinical outcome.

Scrub typhus: a reemerging infection

PURPOSE OF REVIEW

Scrub typhus, caused by Orientia tsutsugamushi, is a widely neglected disease which is gaining global momentum because of its resurgence patterns. The disease is now being reported in newer regions as well as areas previously endemic areas. In this review, we aim to comprehensively review the data available to assist physicians in making an accurate diagnosis and appropriate management of the disease.

RECENT FINDINGS

Several diagnostic tests have been developed for confirming scrub typhus. However, there is lack of clarity on which tests are most appropriate in a given clinical scenario. A recent study has demonstrated that in early disease (<7 days) when serological tests remain negative, the quantitative polymerase chain reaction is the most sensitive test. Among the serological tests, both IgM enzyme-linked immunosorbent assay as well as rapid diagnostic tests revealed excellent sensitivities and specificities.

SUMMARY

With the reemergence of scrub typhus, a high degree of clinical suspicion is required to appropriately diagnose this disease which presents as an acute febrile illness. It can progress to develop various complications leading to multi-organ dysfunction syndrome. Mild illness responds well to antibiotic treatment with doxycycline and azithromycin. Further studies are required to determine the most optimal therapy in severe scrub typhus infections and superiority of one drug over the other.

Rickettsial infections: A blind spot in our view of neglected tropical diseases

Rickettsial diseases are a group of vector-borne bacterial infections that cause acute febrile illness with potentially severe or fatal complications. These vector-borne diseases are prevalent in tropical and subtropical regions worldwide and disproportionately affect poorer communities but are scientifically underrecognized. Despite this, they are not included in the World Health Organization's list of neglected tropical diseases nor were they mentioned in Peter Hotez's recent reflections on "What constitutes a neglected tropical disease?" in PLOS Neglected Tropical Diseases [1]. Here we present the case that rickettsial infections, as an overlooked cause of morbidity, mortality, and economic losses in marginalized populations, should be recognized as neglected tropical diseases. We describe how this oversight is the result of a number of factors and how it negatively impacts patient outcomes. We then propose measures to address the neglect of rickettsial infections in both scientific research and public health interventions.

Multi-country investigation of the diversity and associated microorganisms isolated from tick species from domestic animals, wildlife and vegetation in selected african countries

In many areas of Africa, recent studies highlighted the great impact of ticks on animal and human health throughout the continent. On the other hand, very limited information on the bacterial endosymbionts of the African ticks and their pattern of co-infections with other bacteria are found in literature, notwithstanding their pivotal role in tick survival and vector efficiency. Thus, we investigated the distribution of selected pathogenic and symbiotic bacteria in hard ticks collected from wild, domestic animals and from vegetation in various ecological zones in Africa and their co-occurrence in the same tick host. Overall, 339 hard ticks were morphologically identified as belonging to the genera Amblyomma, Dermacentor, Hyalomma, Haemaphysalis, Ixodes and Rhipicephalus. Molecular screening provided information on pathogens circulation in Africa, detecting spotted fever group rickettsiae, Anaplasma spp., Ehrlichia ruminantium, Borrelia garinii, Babesia spp., Theileria spp. and Coxiella burnetii. Furthermore, our work provides insights on the African scenario of tick-symbiont associations, revealing the presence of Coxiella, Francisella and Midichloria across multiple tick populations. Coxiella endosymbionts were the most prevalent microorganisms, and that with the broadest spectrum of hosts, being detected in 16 tick species. Francisella was highly prevalent among the Hyalomma species tested and correlated negatively with the presence of Coxiella, showing a potential competitive interaction. Interestingly, we detected a positive association of Francisella with Rickettsia in specimens of Hy. rufipes, suggesting a synergistic interaction between them. Finally, Midichloria was the most prevalent symbiont in Rhipicephalus sanguineus sensu lato from Egypt.

Health problems in travellers to Nepal visiting CIWEC clinic in Kathmandu - A GeoSentinel analysis

BACKGROUND

Nepal has always been a popular international travel destination. There is limited published data, however, on the spectrum of illnesses acquired by travellers to Nepal.

METHODS

GeoSentinel is a global data collection network of travel and tropical medicine providers that monitors travel-related morbidity. Records for ill travellers with at least one confirmed or probable diagnosis, were extracted from the GeoSentinel database for the CIWEC Clinic Kathmandu site from January 1, 2009 to December 31, 2017.

RESULTS

A total of 24,271 records were included. The median age was 30 years (range: 0-91); 54% were female. The top 3 system-based diagnoses in travellers were: gastrointestinal (32%), pulmonary (16%), and dermatologic (9%). Altitude illness comprised 9% of all diagnoses. There were 278 vaccine-preventable diseases, most frequently influenza A (41%) and typhoid fever (19%; S. typhi 52 and S. paratyphi 62). Of 64 vector-borne illnesses, dengue was the most frequent (64%), followed by imported malaria (14%). There was a single traveller with Japanese encephalitis. Six deaths were reported.

CONCLUSIONS

Travellers to Nepal face a wide spectrum of illnesses, particularly diarrhoea, respiratory disease, and altitude illness. Pre-travel consultations for travellers to Nepal should focus on prevention and treatment of diarrhoea and altitude illness, along with appropriate immunizations and travel advice.

Tropical Infections in Returning Travelers

In the modern era, the relative ease and faster speed of travel have made the world a global village. An increasing number of people are traveling to distant and sometimes exotic locations for vacation/leisure or at times for business purposes. Along with the experiences of far-fetched lands, sometimes they bring bugs/organisms that are not native to their motherland. This makes the diagnosis and management of illnesses in a traveler challenging. In this review, we have tried to outline a management protocol for travelers returning with fever, with specific emphasis on trypanosomiasis and schistosomiasis.

How to cite this article: Suri V, Bhalla A. Tropical Infections in Returning Travelers. Indian J Crit Care Med 2021;25(Suppl 2):S175–S183.