Special infectious disease risks of expatriates and long-term travelers in tropical countries. Part II: infections other than malaria

Seroprevalence of dengue, Japanese encephalitis and Zika among long-term expatriates in Thailand

BACKGROUND

Travel to Southeast Asia increases the likelihood of acquiring mosquito-borne Flavivirus infections such as dengue (DENV), Japanese encephalitis (JEV) and Zika viruses (ZIKV). Expatriates are long-term travellers who have a higher risk of mosquito-borne illness at their destination country. The purpose of this study was to evaluate the seroprevalence of DENV, JEV and ZIKV infections and the determinants contributing to seropositivity among expatriates living in Thailand.

METHODS

A cross-sectional study was performed from December 2017 to February 2020. Expatriates from non-Flavivirus endemic countries were recruited. 5 mL of blood was collected for DENV 1-4, JEV and ZIKV antibody testing by plaque reduction neutralization test (PRNT50). Individuals with vaccination histories or diagnoses for dengue, Japanese encephalitis, yellow fever and tick-borne encephalitis were excluded.

RESULTS

Among 254 participants, most participants (83.1%) were male, the mean age was 65 years and the median duration of stay in Thailand was 6 years. Seroprevalence rate of any Flavivirus, non-specific DENV, DENV1-4, JEV and ZIKV were 34.3, 30.7, 20.5, 18.1, 18.9, 10.6, 4.7 and 2.8%, respectively. The presence of neutralizing antibodies against DENV1-4 positively correlates with the duration of stay in Thailand. DENV seropositivity was associated with living in urban areas (aOR 2.75, 95% CI 1.36-5.57). Expatriates were unlikely to have detectable anti-JEV antibodies regardless of time spent in a JEV-endemic area. No risk factors were identified that were significantly associated with JEV or ZIKV seropositivity. Only 48.4% received pre-travel counselling services, while only 18.9% visited a travel medicine specialist.

CONCLUSIONS

A high proportion (34.3%) of long-term expatriates living in Thailand were seropositive for flavivirus, mainly from dengue (30.7%). To minimize risk, travel medicine practitioners should provide adequate pre-travel health risk information on mosquito-borne flavivirus infection and offer advice on mosquito bite prevention strategies. Dengue vaccine might be considered in high-risk travellers such as long-term expatriate.

Psychological and Social Aspects of Vaccination Hesitancy-Implications for Travel Medicine in the Aftermath of the COVID-19 Crisis: A Narrative Review

Vaccines are an important tool of preventive medicine. Although organized vaccination programs have saved large populations from serious infectious diseases, there is a considerable part of the population who oppose vaccinations. In particular, anti-vaccination perceptions, among travelers to countries with endemic diseases, are a major public health concern. Although hesitancy towards vaccinations is not a novel phenomenon, it came back to the forefront during the fight against the COVID-19 pandemic. This review explores the etiology of anti-vaccination beliefs among travelers and draws conclusions about their impact on public health and society in general. For this purpose, a purposeful search for data on the causative factors of vaccine hesitancy and their impact on people's health was conducted. A descriptive analysis of the findings and conclusions regarding possible implications in health policy and clinical practice are presented. A fear of side effects, lack of credence in the necessity of vaccines, and mistrust of medical authorities are important causative factors. Their interplay shapes hesitancy towards vaccines. However, anti-vaccination beliefs can also be an aspect of a more general unconventional stance of life. Health care professionals and organizations must be ready to tackle vaccine hesitancy by making the necessary interventions. Correcting misconceptions about vaccinations is a prerequisite for ensuring personal and public health, especially in the context of a pandemic or epidemic. Moreover, ensuring the efficacy and safety of vaccines, especially in cases of modern technology applications, is a fundamental factor in addressing people's concerns about vaccines. For this purpose, medical authorities and organizations must provide accurate and clear information on vaccines so as to eliminate misinformation. Furthermore, clinicians should cultivate their communication skills in order to convey the appropriate messages to prospective recipients of vaccinations.

Reasons for seeking care and adherence to pretravel preparation in expatriate or long-term travelers' children in the tropics: A French prospective study

BACKGROUND

Studies on pediatric travelers' health rarely address expat or long-term travelers' children.

METHOD

To investigate reasons for seeking care and adherence to pretravel preparation, we prospectively enrolled French children 0-15 years old, either expatriates or staying >6 months in tropical areas, who attended a French health center in Africa, Central America or Southern Pacific regions from October 01, 2011 to October 31, 2012. A standardized questionnaire was completed by a general practitioner at each visit, then anonymized and included in our database.

RESULTS

464 questionnaires were collected from 367 children (sex ratio M/F: 1:1). Median age was 6.4 years (IQR: 3.6; 10.3). Reasons for seeking care were mostly infections (n = 378), of which 12 (3.2%) were tropical. There were no deaths, but one child with tuberculosis was repatriated. Coverage was high for routine immunization, but less for travel-related vaccines. Personal antivectorial protection was significantly lower in children aged >5 y or in non-malarial areas. Where indicated, malarial chemoprophylaxis was prescribed to only one third of the children, of whom 60% were poorly compliant. Advice regarding measures against diarrhea and sunburn was followed significantly more for stays >2 yrs.

CONCLUSION

Mild cosmopolitan illnesses predominated but protection against tropical threats should be optimized before and during the stay.

Health Support for a Remote Industrial Site

This publication is derived from and rooted in the authors' experience in designing the Health Support of a remote industrial site. Summarizing the main steps of this design is the purpose of the approach. As a first step devoted to “Evaluation” (Chapters 1–5) are displayed the fundamentals for designing a Project Health Plan, such as a realistic and operative definition of “patient stabilization” and the principles of tactical reasoning for Medevacs, specifying how pathophysiology and logistic constraints should be correlated. A core element of the conceptual work consists in partnering these two domains, which usually each go their own way. Both should be considered in terms of delays: in life threatening situations, pathophysiology allows for a (maximum) delay before effective stabilization, while logistics dictates a (minimum) delay for reaching a stabilization facility. Ensuring that these two delays match is the desired result. Clearly, this conceptual work will unfold its full potential in low sanitary level countries, where most industrial commodities Projects take place, and where these delays are the longest. Next is detailed the audit/study preparation, i.e., the data gathering needed to get a clear picture of the Project conditions and concerns, workforce headcount and pattern, evacuation vectors and delays, and reference documents. Finally, risk assessment and a review of health facilities—in the vicinity and further away—complete the evaluation work. In a second phase devoted to “Implementation” (Chapters 6–9) is detailed how contracts with health providers, and health exhibits of industrial contracts should be conceived, and how on-site health support is designed, from the necessity of a pre-employment check to the design and organization of routine and emergency medicine facilities. Emergency preparedness and response plans, as well as medical coordination, should integrate with the HSE command chart. Overall, this document strongly advocates for joint engineering between HSE officers and medical specialists. An overview of key points for hygiene—often a separate topic covered in an offprint—is proposed. Finally, forward guidance for writing the audit/study report is proposed. This audit/study report must result in conclusive recommendations. Hence, a guide is proposed so that the report becomes a matrix of the Health Plan itself, and will be ended by a summary of findings and recommendations ready-to-use in Project management. In this way, the Health Plan will be launched, and gradually evolve and be amended as a “living document” throughout the lifetime of the Project.

Low incidence of helminth infections (schistosomiasis, strongyloidiasis, filariasis, toxocariasis) among Dutch long-term travelers: A prospective study, 2008-2011

BACKGROUND

Despite the considerable burden of helminth infections in developing countries and increasing international travel, little is known about the risks of infection for travelers.

OBJECTIVE

We studied the attack and incidence rate of serology confirmed strongyloidiasis, filariasis, and toxocariasis among long-term travelers and associated factors. A second objective was to evaluate eosinophilia as a positive/negative predictive value (PPV/NPV) for a recent helminth infection.

METHODS

From 2008 to 2011, clients of the Public Health Service travel clinic planning travel to (sub)tropical countries for 12-52 weeks were invited to participate in a prospective study. Participants kept a weekly diary, recording itinerary, symptoms, and physician visits during travel and completed a post-travel questionnaire. Pre- and post-travel blood samples were serologically tested for the presence of IgG antibodies against Schistosoma species, Strongyloides stercoralis, filarial species, and Toxacara species and were used for a blood cell count. Factors associated with recent infection were analyzed using Poisson regression. Differences among groups of travelers were studied using chi square tests.

RESULTS

For the 604 participants, median age was 25 years (interquartile range [IQR]: 23-29), 36% were male, median travel duration was 20 weeks (IQR: 15-25), and travel purpose was predominantly tourism (62%). Destinations were Asia (45%), Africa (18%), and the Americas (37%). Evidence of previous infection was found in 13/604 participants: antibodies against Schistosoma spp. in 5 (0.8%), against S.stercoralis in 3 (0.5%), against filarial species in 4 (0.7%), and against Toxocara spp. in 1 (0.2%). Ten recent infections were found in 9 participants (3, 1, 6, 0 cases, in the above order), making the attack rates 0.61, 0.17, 1.1 and 0, and the incidence rates per 1000 person-months 1.5, 0.34, 2.6 and 0. The overall PPV and NPV of eosinophila for recent infection were 0 and 98%, respectively.

CONCLUSIONS

The risk of the helminth infections under study in this cohort of long-term travelers was low. Routine screening for eosinophilia appeared not to be of diagnostic value.

Preventing diseases in round-the-world travelers: a contemporary challenge for travel medicine advice

Providing advice for travelers embarking on long-term trips poses a challenge in travel medicine. A long duration of risk exposure is associated with underuse of protective measures and poor adherence to chemoprophylaxis, increasing the chances of acquiring infections. Recently, in our clinic, we observed an increase in the number of travelers undertaking round-the-world trips. These individuals are typically aged around 32 years and quit their jobs to embark on one-to-two-year journeys. Their destinations include countries in two or more continents, invariably Southeast Asia and Indonesia, and mostly involve land travel and visiting rural areas. Such trips involve flexible plans, increasing the challenge, especially with regard to malaria prophylaxis. Advising round-the-world travelers is time-consuming because of the amount of information that must be provided to the traveler. Advisors must develop strategies to commit the traveler to his/her own health, and verify their learnings on disease-prevention measures. Contacting the advisor after the appointment or during the trip can be helpful to clarify unclear instructions or diagnosis made and prescriptions given abroad. Infectious diseases are among the most frequent problems affecting travelers, many of which are preventable by vaccines, medicines, and precautionary measures. The dissemination of counterfeit medicines, particularly antibiotics and antimalarial medicines, emphasizes the need for travelers to carry medicines that they may possibly need on their trip. Additional advice on altitude, scuba diving, and other possible risks may also be given. Considering the difficulties in advising this group, we present a review of the main recommendations on advising these travelers.

Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet

BACKGROUND

International travellers are at risk of travel-related, vaccine-preventable diseases. More data are needed on the proportion of travellers who refuse vaccines during a pre-travel health consultation and their reasons for refusing vaccines.

METHODS

We analyzed data on travellers seen for a pre-travel health consultation from July 2012 through June 2014 in the Global TravEpiNet (GTEN) consortium. Providers were required to indicate one of three reasons for a traveller refusing a recommended vaccine: (1) cost concerns, (2) safety concerns or (3) not concerned with the illness. We calculated refusal rates among travellers eligible for each vaccine based on CDC recommendations current at the time of travel. We used multivariable logistic regression models to examine the effect of individual variables on the likelihood of accepting all recommended vaccines.

RESULTS

Of 24 478 travellers, 23 768 (97%) were eligible for at least one vaccine. Travellers were most frequently eligible for typhoid (N = 20 092), hepatitis A (N = 12 990) and influenza vaccines (N = 10 539). Of 23 768 eligible travellers, 6573 (25%) refused one or more recommended vaccine(s). Of those eligible, more than one-third refused the following vaccines: meningococcal: 2232 (44%) of 5029; rabies: 1155 (44%) of 2650; Japanese encephalitis: 761 (41%) of 1846; and influenza: 3527 (33%) of 10 539. The most common reason for declining vaccines was that the traveller was not concerned about the illness. In multivariable analysis, travellers visiting friends and relatives (VFR) in low or medium human development countries were less likely to accept all recommended vaccines, compared with non-VFR travellers (OR = 0.74 (0.59-0.95)).

CONCLUSIONS

Travellers who sought pre-travel health care refused recommended vaccines at varying rates. A lack of concern about the associated illness was the most commonly cited reason for all refused vaccines. Our data suggest more effective education about disease risk is needed for international travellers, even those who seek pre-travel advice.

Respiratory infections in travelers returning from the tropics

Respiratory tract infections (RTIs), beside diarrheas, skin lesions, and fevers of unknown origin, are one of the most common health problems acquired by travelers going to tropical and subtropical countries. Visitors to African, Asian, or South American destinations, typically characterized by harsh environmental conditions and poor sanitation standards, are at risk of exposure to a large number of pathogens causing infectious diseases. The infections are transmitted from contaminated food and water, through the air, direct contact, or by insects. The main modes of RTIs transmission include droplet infection and direct contact. The clinical spectrum of RTIs in travelers is broad, from upper respiratory tract infections, pharyngitis, bronchitis, pneumonia, to influenza-like illness. The spectrum of microbial agents causing respiratory infections include numerous viruses and bacteria, rarely fungi, and parasites. Most travelers complain of mild infections, only a small minority seek medical assistance and report to health care facilities. Because of the risk of importing pathogens into Europe or North America and transferring them onto the local population, it is important to present the scale of the problem in relation to rapid development of tourism industry and an increasing number of intercontinental journeys. The aim of the study was to discuss the occurrence of travel-related respiratory infections among representatives of temperate climate traveling to and returning from the tropics.

Health hazards and medical treatment of volunteers aged 18-30 years working in international social projects of non-governmental organizations (NGO)

The specific health risk profile and diversity of treatments sought by young volunteers participating in international social projects should differ from those of their older colleagues. In the absence of any data to identify whether this was correct, a retrospective analysis was performed using a standardized questionnaire. Questions included what diseases occurred, and details of the frequency and types of treatment sought during their stay - (e.g. self-treatment, medical/dental intervention, or local healer). The 153 participants were aged 18-30 years and worked in a non-governmental organization for >6 months. The participants were: 53% female, mean age 20 years, and mean duration of stay was 11.2 months. Their NGO placement abroad was in Latin America 65.4%, 14.4% in Africa, and 9.8% in Asia. 83% of the young volunteers had received some advice regarding travel medicine before their departure. However, they suffered from more injuries compared to private travellers, and febrile infections were more common when compared to older studies. 21.2% suffered from dental problems and 50% of them sought medical treatment. This study highlights a previously unreported higher risk profile of specific health problems occurring in young NGO volunteers, including some potentially life-threatening diagnoses that differed from their older colleagues and normal travellers. It is recommended that young volunteers should receive age specific, comprehensive pre-departure training in health and safety, first aid, and management of common health problems. A medical check-up upon returning home should be mandatory. The provision of a basic first aid kit to each volunteer before departure is also recommended.

Expatriates: special considerations in pretravel preparation

Expatriates comprise a diverse set of travelers who face unique medical, psychiatric, and non-health-related risks as a result of increased exposure to host country environment and associated lifestyle. Expatriates have an increased risk of developing malaria, gastrointestinal disorders, latent tuberculosis, vaccine-preventable infections, and psychological disorders, when compared with other travelers, yet the majority of existing pretravel guidelines have been designed to suit the needs of nonexpatriates. Although greater interest in expatriate health issues has led to improved characterization of illness in this population, expatriate-specific risk mitigation strategies-including modifications to chemoprophylaxis recommendations, limiting tuberculosis exposure, and prevention of occupational or sexual blood-borne virus transmission-are poorly described. Occupations and destinations affect travel-related disease risk and should inform the pretravel consultation.

Systematic review and meta-analysis of TST conversion risk in deployed military and long-term civilian travelers

BACKGROUND

Transmission of tuberculosis (TB) during travel is a significant potential infectious disease threat to travelers. However, there is uncertainty in the travel medicine community regarding the evidence base for both estimates of risk for latent TB infection (LTBI) in long-term travelers and for information regarding which travelers may benefit from pre- or post-travel TB screening. The purpose of this study was to determine the risk for tuberculin skin test (TST) conversion, used as a surrogate for LTBI, in long-term travelers from low- to high-risk countries.

METHODS

We performed a systematic review to acquire all published and unpublished data on TST conversion in long-term civilian and military travelers from 1990 to June 2008. Point estimates and confidence intervals (CIs) of the incidence of TST conversion were combined in a random effects model and assessed for heterogeneity.

RESULTS

The cumulative risk with CI for LTBI as measured by TST conversion was 2.0% (99% CI: 1.6%-2.4%). There was a marked heterogeneity (chi(2) heterogeneity statistic, p < 0.0001) which could not be explained by evaluable study characteristics. When stratifying by military and civilian studies, the cumulative risk estimate was 2.0% (99% CI: 1.6-2.4) for military and 2.3% (99% CI: 2.1-2.5) for civilian studies.

CONCLUSION

The overall cumulative incidence of 2.0% is what could be expected to occur among the local population in many developing-country settings, though TST conversion likely overestimates the risk of TB infection because of the low positive predictive value (PPV) of the TST in low-prevalence populations such as travelers. To maximize the PPV of a screening test for LTBI, a targeted testing strategy for long-term military and civilian travelers is recommended, based on exposures known to increase the risk of TB. Studies to better define higher risk groups, activities, and locations are needed.

Health risks and risk-taking behaviors among International Committee of the Red Cross (ICRC) expatriates returning from humanitarian missions

OBJECTIVE

To assess self-reported health risk and risk-taking behavior of humanitarian expatriates.

METHODS

A self-administered anonymous questionnaire was completed by International Committee of the Red Cross (ICRC) expatriates returning during May 2003 to September 2004, covering perceived health status before and after mission, malaria prevention, prevalence of exposure to stress, accidents and violence, and risk-taking behaviors.

FINDINGS

More than one-third (36.4%) reported worse health on return from the mission. A third (35%) of expatriates returning from Sub-Saharan Africa excl. South Africa reported not having followed ICRC's recommendation on taking malaria prophylaxis in spite of stating a high degree of awareness of the risks and availability of effective drugs. Over 40% reported the mission having been more stressful than expected, mostly due to the working environment; 10% reported injury or accidents and 16.2% exposure to at least one act of violence. Almost one-third of the respondents reported having engaged in casual sexual relationships. Of these, 64% reported using condoms at every sexual contact, and women reported lower usage of condoms than men. Many (27%) reported involvement in risk-taking behavior.

CONCLUSION

This study shows that humanitarian aid workers experience significant worsening of their health during overseas missions. Many are at risk of experiencing violence, accidents, or injuries. Despite awareness of the risks, many expatriates engage in behaviors that could endanger their health. Improved selection of expatriate staff, training programs emphasizing areas of concern, strengthening social support locally, and follow-up in field may help to alleviate these problems.

Travel health care for immigrant children visiting friends and relatives abroad: retrospective analysis of a hospital-based travel health service in a US urban underserved area

BACKGROUND

There is a lack of studies evaluating pre-travel health care for children who travel to visit friends and relatives (VFR). We evaluated travel health services provided to children VFR travelers (CVFRs) as compared with adult VFR travelers (AVFRs). CVFRs and AVFRs were also compared with children and with adults traveling as tourists (CTs and ATs, respectively), to explore relevant differences within each age group between VFRs and tourist travelers.

METHODS

Retrospective chart review of all pre-travel consultations from March 2005 to July 2006 at the Bronx-Lebanon Hospital Center travel health clinic, Bronx, New York.

RESULTS

Of 204 pre-travel consultations, 51% comprised CVFRs, 20% AVFRs, 7% CTs, and 23% ATs. About 54, 44, 57, and 30% of CVFRs, AVFRs, CTs, and ATs, respectively, presented within 14 days of departure. CVFRs were more likely than AVFRs and CTs to plan long-term travel (> 6 months). CVFRs and AVFRs traveled mostly to West Africa (75 and 73%) in contrast to CTs and ATs (7 and 35%). Mefloquine was the most frequently prescribed antimalarial medication overall (70%) and among CVFRs (94%). Yellow fever vaccine was most frequently administered overall and to CVFRs and AVFRs followed by hepatitis A, typhoid fever, and meningococcal vaccine. CTs were more likely than CVFRs to receive rabies vaccine. Delayed yellow fever administration (< 10 d before departure) was noted for 48% of CVFRs and 33% of AVFRs.

CONCLUSIONS

CVFRs frequently plan to travel for long-term trips to West Africa and present late for pre-travel care. Routine screen for high-risk travel activities and coordination of pre-travel care within the routine preventive health care may improve the effectiveness of the travel health services.

Clinicoepidemiological characteristics of HIV-infected immigrants attended at a tropical medicine referral unit

BACKGROUND

Migration is a growing phenomenon with a well-known impact in infectious diseases epidemiology. Currently, immigrants represent almost 10% of the Spanish population. The majority come from countries where the prevalence of chronic viral illnesses is higher than in Spain.

METHODS

To describe clinicoepidemiological features of human immunodeficiency virus (HIV)-infected immigrants attending our Unit and to compare differential characteristics depending on geographical origin, information from all new immigrants from January 1997 to December 2006 was collected.

STUDY DESIGN

noninterventional retrospective chart review.

RESULTS

We screened 1,609 patients of whom 77 (4.8%) were HIV antibody (Ab) positive. Of these, 80% were sub-Saharan Africans (SSAFR) and 20% were South-Central Americans (SCA). HIV prevalence was higher in SSAFR (5.6% vs 3.2%; p= 0.04). Overall, of those who were HIV Ab positive, 70% were male (median age 30 years), 59% heterosexuals, 9% hepatitis C virus coinfected, 8.6% hepatitis B virus coinfected, and 34% showed a positive tuberculin skin test. Median CD4 cell count was 263 cells/microL, median HIV-ribonucleic acid viral load 4.6 Log/mL, and 48% had a late diagnosis [acquired immunodeficiency syndrome (AIDS)-defining illness or <200 CD4 microL at the time of diagnosis]. Only 68% of patients for whom antiretroviral therapy was indicated actually started therapy and 22% were lost to follow-up just after diagnosis. SCA had lower CD4 cell counts (26 vs 168 cells/microL; p= 0.016), higher viral loads (5.3 vs 4.8 Log; p= 0.001), and were more likely to have an AIDS-defining illness (53% vs 21%; p= 0.04) compared to SSAFR. Tuberculin skin test reactivity was more common among SSAFR versus SCA [adjusted by CD4 count, odds ratio (OR) 6.3 and 95% confidence interval (CI): 0.65-60.5]. The main risk factor for late diagnosis was geographical origin: OR 4.6 (95% CI: 1.11-19.3) (SCA vs SSAFR; adjusted by the interval between the date of arrival in Spain and the date of HIV diagnosis).

CONCLUSIONS

Almost half the HIV-infected immigrants were diagnosed in late stages. Patients were frequently lost to follow-up, and a significant minority did not start highly active antiretroviral therapy when indicated. SCA seem to have more severe immunosuppression at the time of diagnosis than SSAFR. Early voluntary routine HIV screening should be promoted.

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.

Knowledge and use of measures to reduce health risks by corporate expatriate employees in western Ghana

BACKGROUND

Expatriate corporate workers stationed in remote regions of developing countries with limited health care resources are at substantial risk for a variety of infectious diseases.

METHODS

A survey was carried out among expatriates working at a large power plant construction site in western Ghana in 1998 to evaluate their use of pretravel medical services, current knowledge, and behavioral practices in relation to food- and waterborne disease prevention, diarrhea, malaria, respiratory infections, alcohol use, and high-risk sexual activity. An anonymous, structured, and pretested questionnaire was used.

RESULTS

The response rate was 42 of 60 (70%). Most respondents were men (39 of 42, 93%) with previous international construction experience. Adherence to food and water safety recommendations decreased with time. Expatriates (15 of 23, 65%) from developed countries reported at least one episode of diarrhea, whereas no expatriates (0 of 9) from resource-poor countries reported diarrhea (p < 0.001). Use of malaria chemoprophylaxis deteriorated with increasing duration of time on the job site. None of the expatriates (0 of 9) who had been on the site for more than a year was still taking an antimalarial compared to those who had been there for 3 months or less (13 of 16) (p < 0.01). Forty-three percent (18 of 42) of the respondents reported having had a respiratory infection in the past 3 months. Only 38% (15 of 39) received preplacement education on human immunodeficiency virus (HIV) risk. A higher proportion of those who received pretravel HIV education used condoms always (4 of 5) than those who did not receive HIV education (1 of 5).

DISCUSSION

The use of health advice and preventive measures was generally low among the expatriate corporate survey respondents. Adherence to preventive measures declined with the increase in length of stay. Corporations need to develop appropriate health promotion strategies targeting their expatriates in developing countries.