Prospective analysis of parasitic infections in Canadian travelers and immigrants

Larva Currens: Report of Seven Cases and Literature Review

Strongyloidiasis is a frequent and often unrecognized parasitic disease because of the frequently asymptomatic nature and lack of sensitivity of diagnostic tests. Under conditions of immunosuppression (particularly systemic corticosteroid treatment), potentially fatal dissemination may occur. Thus, prevention and early diagnosis are important. Larva currens is a rare and pathognomonic cutaneous sign of strongyloidiasis, but is poorly described because of its unpredictable and fleeting occurrence. We report seven imported cases of larva currens seen in Paris between 1990 and 2020. We illustrate the clinical and biological features of this specific but uncommon sign of strongyloidiasis with clinical pictures. There were three males and four females, aged between 29 and 58 years. There were five migrants from endemic countries, one tourist and one expatriate. Digestive disorders were the main extracutaneous signs. All patients had eosinophilia above 0.5 G/L. All cases were confirmed by stool tests. All were cured with ivermectin. The rapidity and the short duration of the creeping eruption distinguish it from other parasitoses. Ivermectin is a treatment of choice. The key point is to think about preventing disseminated strongyloidiasis before giving corticosteroids not only among migrants but also among expatriates and tourists in endemic countries.

Amoebic toxic megacolon with poly-helminthic coinfection: Case presentation and review of intestinal polyparasitic infections

INTRODUCTION

Intestinal parasitic infections are a health burden to developing countries, but can also become more prevalent worldwide, even in developed countries, with the advent of globalization. While most of these infections are benign, some may be associated with acute infections with high morbidity and mortality rates.

CASE PRESENTATION

A 36 years old patient presented with toxic megacolon with poly-helminthic infections, likely a result of raw food ingestion. She subsequently required multiple surgeries with a total colectectomy and small bowel resection, and ended up with an end-ileostomy.

DISCUSSION

Intestinal polyparasitism has been reported in undeveloped countries, but it appears that such a trend can be found in developed countries as well. Clinicians, especially those practicing in countries with large expatriate or immigrant worker populations, should be aware of this trend and adjust treatment protocols accordingly.

CONCLUSION

Even in countries whereby intestinal parasitic infections are not common, clinicians should have a heightened awareness of the possibility for such infections to be present, especially in returning travellers, expatriate or immigrant populations.

2018 in review: five hot topics in tropical medicine

The year 2018 heralded many new developments in the field of tropical medicine, including licensure of novel drugs for novel indications, licensure of existing drugs for existing indications but in novel settings, and globalized outbreaks of both vector-borne and zoonotic diseases. We herein describe five top stories in tropical medicine that occurred during 2018, and illuminate the practice-changing development within each story.

Prolonged antibiotic use leading to Clostridium difficile colitis in an ill returned traveller with acute fascioliasis

We report a case of a 29-year-old woman who presented to hospital with fever, right upper quadrant pain, marked eosinophilia, and liver abscesses after returning to Canada from Bali, Indonesia. Diagnostic delay and prolonged antibiotic use led to morbidity before the eventual diagnosis and treatment of fascioliasis.

Helminthic infections in returning travelers and migrants with eosinophilia: Diagnostic value of medical history, eosinophil count and IgE

OBJECTIVES

Eosinophilia in travelers and migrants returning from the tropics is often associated with invasive helminthic infections. Total IgE is considered a useful additional diagnostic parameter; however, both parameters are also increased in various other non-helminthic diseases.

METHODS

We retrospectively evaluated travelers and migrants seen at our department between September 2007 and May 2014. Patients with an absolute eosinophil count ≥500 cells/μl were considered for further analyses.

RESULTS

Among 6618 returned travelers and migrants, 154 (2.3%) had a total eosinophil count ≥500 cells/μL. Of these, 71 patients (46%) were diagnosed with helminthic infection. In an additional 62 patients (40%) with eosinophilia a final diagnosis was found, including non-helminthic infections in 34 patients and non-infectious causes in 28 patients, while in 21 patients (14%) no diagnosis was made. Patients with helminthic infections had higher eosinophil counts than travelers and migrants with other diagnoses (median 981 vs. 710 cells/μl; p = 0.001), while total IgE levels (n = 70; 172 vs. 152 kU/l; p = 0.731) were similar in both groups.

CONCLUSION

Eosinophil count but not total IgE levels are associated with helminthic infections in returning travelers and migrants with eosinophilia. Our results do not support the use of total IgE to differentiate helminthic infections from other causes of eosinophilia in this population.

Medical and psychological problems faced by young Australian gap year travellers

BACKGROUND

Gap year travellers can potentially be exposed to many infectious diseases and other travel-related health problems including injuries and psychological problems. Currently, there is little information on health and wellbeing of this particular group of travellers.

METHODS

Participants were recruited from an organization that specialized in organising international gap year placements. Gap year travellers were asked to complete a pre-departure survey on demographics, placement destination and duration, previous travel experience, hobbies, risk taking behaviour, anticipated problems during the placement, and pre-travel preparations. After the placement, participants were asked to complete a post-trip survey on their experiences, problems, health issues, and medical treatment required.

RESULTS

The 88 and 34 gap year travellers aged 17-23 years completed pre- and post-placement surveys respectively. The duration of placements ranged from 3 to 12 months. Psychological stressors were frequently reported [ n = 26 (76.5%) felt home sick; n = 18 (52.9%) experienced culture shock; n = 17 (50.0%) had difficulty communicating with the locals]. The majority of participants (91.2%) tried to work out a solution for the stressor on their own. Twenty-eight (82.4%) participants reported medical problems during their placement; the most common problems were sunburn ( n = 19; 55.9%), respiratory infections ( n = 15; 44.1%), weight change ( n = 14; 41.2%), and diarrhoea/food poisoning ( n = 13; 38.2%). Three participants (3.4%) were admitted to hospital; for a muscle injury, head injury and skin infection after getting a tribal tattoo.

CONCLUSIONS

Psychological stressors were common, but most did not seek help. Some medical problems encountered during their placement may have been preventable with improved pre-departure preparation.

KEY WORDS

Gap year, pre-departure, preparation.

[Clinical approach to imported eosinophilia]

Eosinophilia is a common finding in international travelers and immigrants, being an helmintic infection its main etiology. The positive predictive value of eosinophilia for an helmintosis is low in travellers. Eosinophilia may be an incidental finding, or symptomatic, and it represents a clinical challenge due to the low sensitivity and specificity of direct and indirect parasitological diagnostic tests, respectively. It requires a structured approach based on geographical areas, environmental exposures and behavioral risks, and associated symptoms. The initial assessment should include a comprehensive and tailored anamnesis and physical examination, basic laboratory tests, a complete parasitological examination of stool samples and a Strongyloides stercoralis serology, supplemented with other explorations guided by epidemiological and clinical suspicion. Empiric treatment with albendazole and/or ivermectin (plus praziquantel if risk of schistosomiasis) is an option for unidentified persistent eosinophilia after study, and in persons in whom a proper assessment or follow-up can not be assured. In patients at risk for estrongiloidosis who are candidates for immunosuppressive therapies, it is indicated a prior screening and treatment to prevent a future hyperinfestation syndrome.

Eosinophilia in Infectious Diseases

In determining the etiology of eosinophilia, it is necessary to consider the type of patient, including previous travel and exposure history, comorbidities, and symptoms. In this review, we discuss the approach to the patient with eosinophilia from an infectious diseases perspective based on symptom complexes.

Imported parasitic infections in Serbia

BACKGROUND

Travel to the tropics is associated with a risk of parasitic infection, which is increasing in parallel with the rise in travel to these areas. We thus examined the prevalence and trend in the occurrence of parasitic infections in Serbian travelers.

METHODS

A retrospective analysis of the medical records of all travelers returning from tropical and subtropical areas, who presented at the Institute for Infectious and Tropical Diseases in Belgrade between January 2001 and January 2008, was performed.

RESULTS

Of a total of 2440 travelers, 169 (6.9%) were diagnosed with a parasitic infection, including malaria in 79, intestinal parasites in 84 (pathogenic species in 30 and non-pathogenic in 54), filariasis in four, and visceral leishmaniasis and fascioliasis in one patient each. Importantly, of the whole series only 583 (23.9%) were symptomatic, of which 19.4% were found to be infected with a parasite. The single pathogenic parasite occurring in asymptomatic patients was Giardia intestinalis.

CONCLUSIONS

Parasitic infection causing symptomatic disease among travelers returning from tropical areas to Serbia is not infrequent. In view of the expected increase in travel to the tropics, diagnostic protocols for tropical parasitic diseases should take these data into account.

A comparison of exposure to risk factors for giardiasis in non-travellers, domestic travellers and international travellers in a Canadian community, 2006-2012

The purpose of this study is to determine how demographic and exposure factors related to giardiasis vary between travel and endemic cases. Exposure and demographic data were gathered by public health inspectors from giardiasis cases reported from the Region of Waterloo from 2006 to 2012. Logistic regression models were fit to assess differences in exposure to risk factors for giardiasis between international travel-related cases and Canadian acquired cases while controlling for age and sex. Multinomial regression models were also fit to assess the differences in risk profiles between international and domestic travel-related cases and endemic cases. Travel-related cases (both international and domestic) were more likely to go camping or kayaking, and consume untreated water compared to endemic cases. Domestic travel-related cases were more likely to visit a petting zoo or farm compared to endemic cases, and were more likely to swim in freshwater compared to endemic cases and international travel-related cases. International travellers were more likely to swim in an ocean compared to both domestic travel-related and endemic cases. These findings demonstrate that travel-related and endemic cases have different risk exposure profiles which should be considered for appropriately targeting health promotion campaigns.

Parasitic infections in travelers and immigrants: part II helminths and ectoparasites

Travel and migration contribute to the emergence of certain parasites which may be imported into nonendemic areas. Noncontrolled importation of food products and animals may also contribute to the diagnosis of infections caused by helminths in nonendemic countries. Some helminth infections such as strongyloidiasis may be life-threatening, especially in immunocompromised patients, and outcome depends on correct diagnosis and treatment. Other helminth infections are neglected tropical diseases associated with chronic disease and/or disability. Major challenges concern the development of improved diagnostic techniques, safer and more effective drug therapies and identification of markers of response to treatment. The study of these imported infections in travelers and immigrants may provide opportunities for research which may not be readily available in resource-poor endemic countries. Updated reviews and guidelines are necessary as new data become available. The second part of this review focuses on infections in travelers and immigrants caused by helminths and ectoparasites.

Summary of the Statement on International Travellers Who Intend to Visit Friends and Relatives

BACKGROUND

Travellers intending to visit friends and relatives (VFRs) are a specific group of travellers who have been identified as having an increased risk of travel-related morbidity.

OBJECTIVE

To provide recommendations for risk reduction in international VFRs.

METHODS

Recommendations regarding VFRs were developed based on available travel medicine literature and CATMAT expert opinion. Specific travel-related risks, including infectious disease epidemiology and burden in this population, were reviewed and recommendations were provided to attempt to mitigate these risks. Previous CATMAT statements related to VFRs were referred to and reiterated.

RECOMMENDATIONS

Rates of travel-related illness in VFRs tend to be higher for many conditions. Disease-specific risk factors and recommendations are discussed throughout this Statement. CATMAT recommends that VFRs' vaccinations be up-to-date and they be counselled on the importance of various risk reduction activities such as the use of malaria prophylaxis, safe sex practices and injury prevention. Pre- and/or post-travel tuberculosis testing is indicated in certain situations.

CONCLUSION

The pre-travel health assessment is an important opportunity to address with VFRs issues regarding health beliefs, health behaviours, current health status and the possibility of pre-existing conditions. Discussions addressing the importance of adherence to health advice and potential challenges to achieving adherence may be necessary.

Autochthonous Hookworm-Related Cutaneous Larva Migrans Disease in Northeastern Italy: A Case Report

Here we report the case of a 42-yr-old patient who presented himself to us with a serpiginous erythematous lesion from the wrist of the right forearm up the arm to the right shoulder A similar lesion of a smaller size was also present in the left forearm. On the basis of clinical manifestations and progression of the lesion, combined with previous treatments and different diagnostic investigations, hookworm-related cutaneous larva migrans (HrCLM) disease was hypothesized. Albendazole was employed as treatment and the resolution of the symptoms confirmed the diagnosis. The relevance of the reported case relies on 3 main aspects: the acquisition of the disease in Italy, the initial treatment with topical corticosteroids that sped up the progression of the cutaneous trail, and the uncommon location of the lesions. Furthermore, the anamnestic data and the laboratory/clinical investigations strongly suggested an occupational exposure to the etiological agent. As illustrated here, HrCLM might represent a challenge for Western physicians in terms of diagnosis, treatment, and ways of acquisition. Describing the clinical presentation and the treatment of cases of cutaneous larva migrans might contribute to early and correct diagnosis, to an increase of our knowledge on this disease, and to an update on its epidemiology.

A simple intervention to prevent cutaneous larva migrans among devotees of the Nallur Temple in Jaffna, Sri Lanka

Background

A cross sectional study conducted during the annual festival at Nallur temple in Jaffna, Sri Lanka, in 2010, showed that the prevalence of cutaneous larva migrants (CLM) among the devotees who performed the side roll ritual was 58.2% (95%CI: 51.2%–65.0%).

Objective

To test the hypothesis that the deworming stray dogs around the temple premises effectively reduces the prevalence of CLM among devotees.

Methodology/Principal Findings

All stray dogs (8) in the vicinity of the temple were treated, with mebendazole (100 mg) crushed and filled into sausages, 10 days before the commencement of festival in 2011. The same procedure was repeated a week later to ensure complete coverage. A cross-sectional study was conducted among 200 systematically selected devotees in August 2011 using an interviewer-administered questionnaire and the clinical examination of the skin. Baermann's technique was used for the recovery of nematode larvae from 40 soil samples collected from the temple premises. Ten samples of dog faeces collected from the same premises were also examined for nematode eggs. Prevalence of CLM among devotees in 2010 (Pre intervention) and 2011(Post intervention) were compared to test the hypothesis. Prevalence of CLM declined from 58% to 8% (Chi-square = 112.90, p<0.001) following the intervention. None of the subjects practiced new precautionary measures compared to the previous year. Soil and fecal samples were negative for parasites.

Conclusions/Significance

Regular dog deworming is an important and effective method for the prevention of CLM among the devotees doing side roll ritual and represents a pragmatic intervention that municipal authorities could perform on annual basis.

A systematic review and meta-analysis of the association between Giardia lamblia and endemic pediatric diarrhea in developing countries

We performed a systematic literature review and meta-analysis examining the association between diarrhea in young children in nonindustrialized settings and Giardia lamblia infection. Eligible were case/control and longitudinal studies that defined the outcome as acute or persistent (>14 days) diarrhea, adjusted for confounders and lasting for at least 1 year. Data on G. lamblia detection (mainly in stools) from diarrhea patients and controls without diarrhea were abstracted. Random effects model meta-analysis obtained pooled odds ratios (ORs) and 95% confidence intervals (CIs). Twelve nonindustrialized-setting acute pediatric diarrhea studies met the meta-analysis inclusion criteria. Random-effects model meta-analysis of combined results (9774 acute diarrhea cases and 8766 controls) yielded a pooled OR of 0.60 (95% CI, .38-.94; P = .03), indicating that G. lamblia was not associated with acute diarrhea. However, limited data suggest that initial Giardia infections in early infancy may be positively associated with diarrhea. Meta-analysis of 5 persistent diarrhea studies showed a pooled OR of 3.18 (95% CI, 1.50-6.76; P < .001), positively linking Giardia with that syndrome. The well-powered Global Enteric Multicenter Study (GEMS) is prospectively addressing the association between G. lamblia infection and diarrhea in children in developing countries.

Parasitic liver disease in travelers

Liver disease is an important source of morbidity among ill returning travelers. Jaundice is one of the most common and obvious symptoms of liver disease, the differential diagnosis of which is extensive, especially in travelers. Jaundice in travelers can arise from both infectious and noninfectious causes. We herein summarize the most common parasitic etiologies that may lead to jaundice in the returned traveler, visitors of friends and relatives, or new immigrants, and describe the etiology, epidemiology, and pathogenesis of clinical features of each.

Short report: Amebiasis-related mortality among United States residents, 1990-2007

Despite the endemic nature of Entamoeba histolytica infection in the United States there is a lack of data on amebiasis-related mortality. We analyzed national death certificate data from 1990 to 2007 to assess the occurrence of amebiasis-related deaths and determine demographic and regional associations. A total of 134 deaths were identified. Mortality rates were highest in males, Hispanics, Asian/Pacific Islanders, and persons 75 years of age and older. An association with human immunodeficiency virus infection was also observed. A declining trend of amebiasis deaths was noted over the 18-year study period. Over 40% of fatal amebiasis cases occurred in residents of California and Texas. United States-born persons accounted for the majority of amebiasis deaths; however, all of the fatalities in Asian/Pacific Islanders and 60% of the deaths in Hispanics were in foreign-born individuals. Although uncommon, amebiasis-related deaths routinely occur in the United States.

Travel-related schistosomiasis, strongyloidiasis, filariasis, and toxocariasis: the risk of infection and the diagnostic relevance of blood eosinophilia

BACKGROUND

This study prospectively assessed the occurrence of clinical and subclinical schistosomiasis, strongyloidiasis, filariasis, and toxocariasis, and the screening value of eosinophilia in adult short-term travelers to helminth-endemic countries.

METHODS

Visitors of a pre-travel health advice centre donated blood samples for serology and blood cell count before and after travel. Samples were tested for eosinophilia, and for antibodies against schistosomiasis, strongyloidiasis, filariasis, and toxocariasis. Previous infection was defined as seropositivity in pre- and post-travel samples. Recent infection was defined as a seroconversion. Symptoms of parasitic disease were recorded in a structured diary.

RESULTS

Previous infection was found in 112 of 1207 subjects: schistosomiasis in 2.7%, strongyloidiasis in 2.4%, filariasis in 3.4%, and toxocariasis in 1.8%. Recent schistosomiasis was found in 0.51% of susceptible subjects at risk, strongyloidiasis in 0.25%, filariasis in 0.09%, and toxocariasis in 0.08%. The incidence rate per 1000 person-months was 6.4, 3.2, 1.1, and 1.1, respectively. Recent infections were largely contracted in Asia. The positive predictive value of eosinophilia for diagnosis was 15% for previous infection and 0% for recent infection. None of the symptoms studied had any positive predictive value.

CONCLUSION

The chance of infection with schistosomiasis, strongyloidiasis, filariasis, and toxocariasis during one short-term journey to an endemic area is low. However, previous stay leads to a cumulative risk of infection. Testing for eosinophilia appeared to be of no value in routine screening of asymptomatic travelers for the four helminthic infections. Findings need to be replicated in larger prospective studies.

Intestinal parasites in immigrants in the city of Naples (southern Italy)

The present study was aimed at carrying out a cross-sectional copromicroscopic survey of helminths and intestinal protozoa in immigrants in Naples (southern Italy). Between October 2008 and November 2009, a total of 514 immigrants were tested comparing the FLOTAC dual technique and the ethyl acetate concentration technique. Combined results of the two techniques served as a diagnostic 'gold' standard and revealed an overall prevalence of parasitic infections of 61.9% (318/514). The ethyl acetate concentration technique detected a low number of positive results (49.0%) and this was confirmed for each helminth/protozoa species detected. Among helminths, Trichuris trichiura (3.9%), hookworms (3.7%) and Ascaris lumbricoides (1.4%) were the most prevalent. Strongyloides stercoralis (0.4%), Enterobius vermicularis (0.4%), Schistosoma mansoni (1.0%), Hymenolepis nana (1.6%) and Taenia spp. (0.2%) were also found, as well as zoonotic helminths, as Trichostrongylus spp. (0.8%) and Dicrocoelium dendriticum (0.8%). As regard to pathogenic protozoa, Blastocystis hominis was the most commonly detected (52.7%), followed by Entamoeba histolytica/Entamoeba dispar/Entamoeba moshkovskii (11.9%) and Giardia duodenalis (4.5%). Several issues concerning diagnosis, epidemiology and public health impact of parasitic infections in immigrants are offered for discussion. In conclusion, the present paper pointed out the need of better diagnosis and cure of the immigrant population in order to improve access to health care of this neglected and marginalised population group, for its own protection and care.

Description and burden of travel-related cases caused by enteropathogens reported in a Canadian community

BACKGROUND

Risk of infections by enteropathogens among individuals traveling outside their country of residence is considered important. Such travel-related cases (TRC) have been poorly estimated and described in Canada.

METHODS

Data from an enhanced, passive surveillance system of diseases caused by enteropathogens within a Canadian community from June 2005 to May 2009 were used to describe TRC in terms of disease (pathogen, symptoms, hospitalization, duration, and timing of sickness relative to return); demographics (age and gender); and travel (destination, length, and accommodation); and to compare them with non-TRC.

RESULTS

Among 1,773 reported cases, 446 (25%) were classified as TRC with 9% of them being new immigrants. The main TRC diseases were campylobacteriosis, salmonellosis, and giardiasis. Disease onset occurred before return in 42% of TRC. Main destinations were Latin America/Caribbean and Asia. No differences by month and year were observed for onset, departure, and return dates. In addition to new immigrants, three subgroups of TRC based on travel destination, length of travel, type of accommodation, and age were identified and some diseases were more frequently observed in these subgroups. Generally, TRC did not differ from domestic cases in terms of age, gender, symptoms, hospitalization, and disease duration. Campylobacter coli and Salmonella enteritidis were significantly more frequent among TRC.

CONCLUSIONS

TRC of diseases caused by enteropathogens that are reportable in Canada represent a significant proportion of the burden of the total diseases. Subgroups of TRC exist and are associated with certain diseases. These results help inform the assessment of the actual risk related to travel for each subgroup of travelers and quantify the attribution of traveling abroad to the overall burden of these gastrointestinal diseases.

Physician use of parasite tests in the United States from 1997 to 2006 and in a Utah Cryptosporidium outbreak in 2007

Parasitic infection is uncommon in the United States, but surveys suggest that physicians test when the presence of parasites is unlikely and fail to order appropriate testing when suspicion is high. Numerous studies confirm that immunoassays are more sensitive for Giardia and Cryptosporidium detection, but our experience was that physicians preferentially used ovum and parasite examination (O&P). We conducted a retrospective study of fecal parasite testing at a referral laboratory nationally (1997 to 2006) and during a Cryptosporidium outbreak (Utah, 2007) to correlate physician use of O&P and enzyme immunoassays (EIAs) with the yield of parasites detected. Nationally, of 170,671 episodes, 76.0% (n = 129,732) included O&P, 27.9% (n = 47,666) included Giardia EIA, and 5.7% (n = 9,754) included Cryptosporidium EIA. Most pathogens were Giardia or Cryptosporidium. More episodes were positive when EIA was performed (n = 1,860/54,483 [3.4%]) than when O&P only was performed (n = 1,667/116,188 [1.4%]; P < 0.001), and EIA was more sensitive than O&P. However, more O&P results were positive among patients with both O&P and EIA performed (2.5%) than among those with O&P only performed (1.4%; P < 0.001), suggesting that patients tested by O&P only may have been at lower risk. During the first 10 weeks of the outbreak, physicians also preferentially used O&P over EIA, but no Cryptosporidium cases were detected by O&P. We conclude that clinicians frequently use O&P testing when test performance and epidemiology support the use of immunoassays or no testing. We recommend that stool O&P be limited to patients with negative immunoassay results and persistent symptoms or individuals at increased risk for non-Giardia, non-Cryptosporidium infection. An evidence-based algorithm for the evaluation of patients with suspected intestinal parasitic infection is proposed.

Pediatric travelers visiting friends and relatives (VFR) abroad: illnesses, barriers and pre-travel recommendations

Global mobility has shown a steady rise in recent years, with increased immigration and international travel. The VFR traveler is a traveler whose primary purpose of travel is to visit friends and relatives (VFR), where there is a gradient of risk between home and destination. Children are more likely to be VFR travelers than adults. Pediatric VFR travelers have higher risks for certain infectious travel-related illnesses and face multiple barriers in receiving comprehensive pre-travel care. This review focuses on the current state of knowledge of the pediatric VFR traveler, including epidemiological risks, barriers to adequate pre-travel services, and specific recommendations for disease prevention.

Vaccine preventable diseases in returned international travelers: results from the GeoSentinel Surveillance Network

Vaccine preventable diseases (VPDs) threaten international travelers, but little is known about their epidemiology in this group. We analyzed records of 37,542 ill returned travelers entered into the GeoSentinel Surveillance Network database. Among 580 (1.5%) with VPDs, common diagnoses included enteric fever (n=276), acute viral hepatitis (n=148), and influenza (n=70). Factors associated with S. typhi included VFR travel (p<0.016) to South Central Asia (p<0.001). Business travel was associated with influenza (p<0.001), and longer travel with hepatitis A virus (p=0.02). 29% of those with VPDs had pre-travel consultations. At least 55% of those with VPDs were managed as inpatients, compared to 9.5% of those with non-VPDs. Three deaths occurred; one each due to pneumococcal meningitis, S. typhi, and rabies. VPDs are significant contributors to morbidity and potential mortality in travelers. High rates of hospitalization make them an attractive target for pre-travel intervention.

Malaria and travellers visiting friends and relatives

Among all travel-acquired illnesses, malaria carries the greatest burden not only considering the number of imported cases but also the potential of a fatal outcome. The increased number of imported malaria cases in developed countries in the last decades has been attributed to the increasing number of travel to tropical destinations in combination with the enormous influx of immigrants. At present, immigrants visiting friends and relatives (VFRs) constitute the most significant group of travellers for malaria importation in developed countries, with sub-Saharan Africa destinations carrying the highest risk. VFRs typically demonstrate travel and behavioural patterns which render them at high risk for acquisition of this largely preventable infection. Pre-travel services are rarely sought by VFRs, whereas misconceptions that they possess life-long immunity against malaria make them less likely to receive or adhere to antimalarial chemoprophylaxis recommendations. There is an urgent need to increase awareness about malaria of this group of travellers.

Eosinophilia in returning travelers and migrants

INTRODUCTION

Eosinophilia in travelers returning from tropical countries is often caused by helminths. The high eosinophil counts arise particularly from tissue migration of invasive larvae.

METHODS

Review of literature selected by means of a Medline search using the MeSH terms "eosinophilia" and "helminth."

RESULTS

The patient's geographic and alimentary history may suggest infection with particular parasitic worms. A targeted diagnostic approach is suggested. The physician should concentrate on the principal signs and be guided by the geographic and alimentary history. Elaborate diagnostic measures are seldom indicated.

DISCUSSION

Although eosinophilia alone has low positive predictive value for a worm infection, it points clearly to helminthosis if the patient has recently returned from the tropics and the eosinophilia is new.

Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans is caused by the migration of animal hookworm larvae in the human skin. The disease mainly occurs in resource-poor communities in the developing world, but it is also reported sporadically in high-income countries and in tourists who have visited the tropics. Diagnosis is made clinically in the presence of a linear serpiginous track moving forward in the skin, associated with itching and a history of exposure. Itching is typically very intense and can prevent patients from sleeping. Bacterial superinfection occurs as a result of scratching. Treatment is based on oral drugs (albendazole or ivermectin) or the topical application of tiabendazole. To control hookworm-related cutaneous larva migrans at the community level, regular treatment of dogs and cats with anthelmintic drugs is necessary, but this is seldom feasible in resource-poor settings. Animals should be banned from beaches and playgrounds. For protection at the individual level, unprotected skin should not come into contact with possibly contaminated soil.

Prevalence and risk factors of hookworm-related cutaneous larva migrans in a rural community in Brazil

The epidemiology of hookworm-related cutaneous larva migrans (HrCLM) in endemic communities is not well understood. To describe the prevalence of HrCLM and to identify environmental and behavioural risk factors for the infestation, two cross-sectional surveys were conducted in a small village in an endemic area of north-eastern Brazil - one in the rainy season and the other in the dry season. The members of each household were examined clinically for the presence of HrCLM, and information on possible risk factors was collected. HrCLM, which was diagnosed in 45 individuals in the rainy-season survey and in 17 in the dry-season survey, was significantly more prevalent in the rainy season (4.4% v. 1.7%; P<0.001). The age-specific prevalences peaked, at 14.9%, in infants and children aged < or = 4 years. In a logistic regression analysis, the independent risk factors for current infestation or infestation in the preceding 6 months were identified as young age (odds ratio = 0.96; 95% confidence interval = 0.94-0.98), living in a house without a solid floor (odds ratio = 1.99; 95% confidence interval = 1.22-3.23), and walking barefoot (odds ratio = 1.77; 95% confidence interval = 1.12-2.80). In the study area, therefore, HrCLM is a common parasitic skin disease in children, is associated with behavioural and environmental risk factors, and shows marked seasonality in its prevalence. Local control of HrCLM should be based primarily on the health education of mothers and the elder girls who take care of their younger siblings.

Cutaneous larva migrans and tungiasis in international travelers exiting Brazil: an airport survey

BACKGROUND

Hookworm-related cutaneous larva migrans (CLM) and tungiasis are commonly diagnosed in travelers returning from endemic areas, but reliable data on disease occurrence do not exist. To describe the occurrence of CLM and tungiasis in international travelers, a cross-sectional study was done.

METHOD

We conducted an airport survey in European travelers exiting northeast Brazil. Questionnaires were distributed at the departure gate of the international airport of Fortaleza (Ceará State) while passengers were waiting to board their plane. The questionnaire included questions on personal characteristics, pretravel health advice, acquired parasitic skin diseases during their stay in Brazil, and clinical characteristics of the infestation. To help identify CLM and tungiasis, photographs of the typical appearances of the infestations were presented.

RESULTS

Data from 372 tourists (aged 16-76 y, median = 40 y) were available for analysis; 45% had obtained pretravel health advice, usually from travel clinics (46.2%) and Internet sites (39.6%). Only 14% of those who obtained advice had been informed about CLM as a travel health risk and 22% about tungiasis. During their stay in Brazil, 12 (3.2%) tourists had experienced tungiasis and 3 (0.8%) CLM. In all cases, lesions were confined to the feet. The three travelers with CLM complained of irritability; itching was present in two cases. Pain (58.3%) and itching (50%) were the most common symptoms in travelers with tungiasis. The length of stay was a clear predictor for tungiasis, with a 20 times higher occurrence in travelers who had stayed for more than 4 weeks in Brazil.

CONCLUSIONS

Tungiasis and CLM are not rare in international tourists departing from Brazil, and pretravel counseling is insufficient. Pretravel health advice should include information on the risk of acquiring tungiasis and CLM and how to prevent an infestation. Airport surveys using questionnaires can be used to obtain incidence data on both parasitic infestations.