Illness in long-term travelers visiting GeoSentinel clinics

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.

Epidemiological and clinical analysis of polish short-term and long-term travelers returning from tropical countries

BACKGROUND

There is a lack of information about health problems after returning from tropical countries among travelers from Poland. The aim was to create characteristics of diseases imported to Poland from tropical regions and to determine the changes in the travel trends.

METHOD

This retrospective study is based on medical records of 2391 Polish patients >18 years old, hospitalized between 2006 and 2016 after returning from tropical areas. The analysis covered purpose, duration and travel destination, and health problems related to the travel. 1098 patients (short travel, <1 month, n = 345 vs long travel, >6 months, n = 753) were selected for further analysis.

RESULTS

The most frequently visited region was Sub-Saharan Africa. Tourists dominated among short-term and missionaries among long-term travelers. The most popular health problems in both groups were digestive system disease and febrile diseases. Diarrhoea of undetermined aetiology, dengue fever, malaria, fever of unknown aetiology and infectious mononucleosis were more likely to occur among short-term travelers whereas blastocystosis, giardiasis, schistosomiasis among long-term travelers. In the group of long-term travelers 363/753 (47,8%) were diagnosed with an infectious or parasitic disease in relation to a trip to a country with a hot climate.

CONCLUSIONS

Tropical diseases occur among Polish travelers so they should be taken into account in the context of prophylaxis when preparing for travel and in the diagnosis of diseases that occur after returning from a tropical zone. This first analysis of disease incidence among Polish travelers indicates a strong need for more research in this area.

Infectious diseases and predominant travel-related syndromes among long-term expatriates living in low-and middle- income countries: a scoping review

Introduction

Expatriates working in low-and middle-income countries have unique health problems. Migration leads not only to an increase in individual health risk but also a risk of global impact, such as pandemics. Expatriates with no prior experience living in tropical settings have expressed greatest concern about infectious diseases and appropriate peri-travel consultation is essential to expatriates. The objective of this review is to describe infections and travel-related syndromes among expatriates living in low-and middle-income countries.

Methods

MEDLINE database since the year 2000 was searched for relevant literature. Search terms were “long-term travel”, “expatriate”, and “health problems”. The additional references were obtained from hand-searching of selected articles.

Results

Up to 80% of expatriates suffered from gastrointestinal problems followed by dermatologic problems (up to 40%), and febrile systemic infection/vector-borne/parasitic infection (up to 34%) Expatriates living in Southeast Asia were at risk of vector-borne diseases including dengue and non-Plasmodium falciparum (pf) malaria while expatriates living in South Asia had a high prevalence of acute and chronic diarrhea. Staying long-term in Africa was related to an elevated risk for pf malaria and gastrointestinal infection. In Latin America, dermatologic problems were commonly reported illnesses among expatriates.

Conclusion

Certain health risks for expatriates who are going to depart to specific regions should be the focus of pre-travel consultation. Specific health preparations may reduce the risk of disease throughout their time abroad. Disease and symptom awareness is essential for screening, early diagnosis, and better health outcomes for ill-expatriates.

High-risk US international travelers seeking pretravel consultation during the COVID-19 pandemic

Background

To assess the implications of coronavirus disease 2019 (COVID-19)–related travel disruptions, we compared demographics and travel-related circumstances of US travelers seeking pretravel consultation regarding international travel at US Global TravEpiNet (GTEN) sites before and after the initiation of COVID-19 travel warnings.

Methods

We analyzed data in the GTEN database regarding traveler demographics and travel-related circumstances with standard questionnaires in the pre-COVID-19 period (January–December 2019) and the COVID-19 period (April 2020–March 2021), excluding travelers from January to March 2020. We conducted descriptive analyses of differences in demographics, travel-related circumstances, routine and travel-related vaccinations, and medications.

Results

Compared with 16 903 consultations in the pre-COVID-19 period, only 1564 consultations were recorded at GTEN sites during the COVID-19 period (90% reduction), with a greater proportion of travelers visiting friends and relatives (501/1564 [32%] vs 1525/16 903 [9%]), individuals traveling for >28 days (824/1564 [53%] vs 2522/16 903 [15%]), young children (6 mo–<6 y: 168/1564 [11%] vs 500/16 903 [3%]), and individuals traveling to Africa (1084/1564 [69%] vs 8049/16 903 [48%]). A smaller percentage of vaccine-eligible travelers received vaccines at pretravel consultations during the COVID-19 period than before, except for yellow fever and Japanese encephalitis vaccinations.

Conclusions

Compared with the pre-COVID-19 period, a greater proportion of travelers during the COVID-19 period were young children, were planning to visit friends and relatives, were traveling for >28 days, or were traveling to Africa, which are circumstances that contribute to high risk for travel-related infections. Fewer vaccine-eligible travelers were administered travel-related vaccines at pretravel consultations. Counseling and vaccination focused on high-risk international travelers must be prioritized during the COVID-19 pandemic.

Amebiasis and Amebic Liver Abscess in Children

Although rare in the developed world, amebiasis continues to be a leading cause of diarrhea and illness in developing nations with crowding, poor sanitation, and lack of clean water supply. Recent immigrants or travelers returning from endemic regions after a prolonged stay are at high risk of developing amebiasis. A high index of suspicion for amebiasis should be maintained for other high-risk groups like men having sex with men, people with AIDS/HIV, immunocompromised hosts, residents of mental health facility or group homes. Clinical presentation of intestinal amebiasis varies from diarrhea to colitis and dysentery. Amebic liver abscess (ALA) is the most common form of extraintestinal amebiasis. Various diagnostic tools are available and when amebiasis is suspected, a combination of stool tests and serology should be sent to maximize the yield of testing. Treatment with an amebicidal drug such as metronidazole/tinidazole and a luminal cysticidal agent such as paromomycin for clinical disease is indicated. However, for asymptomatic disease treatment with a luminal cysticidal agent to decrease chances of invasive disease and transmission is recommended.

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.

A descriptive analysis of dengue in Peace Corps Volunteers, 2000-2019

BACKGROUND

Peace Corps Volunteers (PCVs) are a unique expatriate population at risk for dengue. Previous studies examined travelers or lacked demographic information about expatriates. We examined dengue incidence among PCVs before and after deployment of an electronic medical record (EMR) to assess temporal and demographic factors.

METHODS

Dengue cases within Peace Corps' Epidemiologic Surveillance System from 2000 to 2019 were identified using a standard case definition, and two timeframes were compared: pre-EMR 2000-2015 and post-EMR 2016-2019.

RESULTS

Annual infections occurred in a roughly 3-year cyclic pattern from 2007 to 2019. Incidence rate decreased from 1.35 cases per 100 dengue Volunteer-years (95% CI 1.28-1.41) in 2000-2015 to 1.25 cases (95% CI 1.10-1.41) in 2016-2019. Among PCVs who served from 2016 to 2019, the majority of infections occurred in females and 20-29 year olds, and 7% were medically evacuated. Among PCVs who served from 2015 to 2019, 21% were hospitalized in-country.

CONCLUSIONS

Among PCVs, a non-significant decrease in dengue incidence occurred from 2000-2015 to 2016-2019. Annual infection rates peaked every three years, offering opportunities for targeted prevention efforts. Dengue infection in PCVs appears to mimic the overall demographic of Peace Corps. Expatriates like PCVs are at an increased risk for dengue infection compared to short-term travelers.

Travel patterns, risk behaviour and health problems of travellers with rheumatic diseases compared to controls: A multi-centre, observational study

BACKGROUND

Patients with chronic conditions travel around the world more than ever. Only few studies have examined travel patterns and health outcomes of patients with rheumatic diseases during international travel.

METHOD

We conducted a multi-centre prospective cohort study in Switzerland, in which we studied the immunogenicity and safety of vaccinations in patients with rheumatic diseases and travellers without rheumatic diseases (controls). Participants who travelled internationally received questionnaires 1 and 13 weeks post-travel. We compared travel patterns, risk behaviours, and travel-associated problems during and after the trips in both groups.

RESULTS

274 participants returned post-travel questionnaires (65 rheumatic patients, 209 controls). Controls more frequently travelled to subtropical/tropical destinations and stayed longer abroad. 64% of all participants experienced health problems during travel (74% rheumatic patients vs. 62% controls, P = 0.11). Pre-travel, patients reported a higher susceptibility to gastrointestinal infections . During travel, a higher percentage of rheumatic patients cancelled the day programme due to health problems (13% vs. 4%, P = 0.024). The main problems in rheumatic patients occurred due to the underlying rheumatic diseases, or were of psychological nature. Although not statistically significant, infectious disease symptoms (rhinitis, cough) occurred more frequently in controls. When only considering subtropical/tropical destinations, rheumatic patients more frequently had gastrointestinal problems during travel - and skin infections after the trip.

CONCLUSIONS

This study does not support the notion that patients with rheumatic diseases should avoid international travel for an increased risk of infections. In patients with subtropical/tropical destinations, however, gastrointestinal problems may be increased during travel - and skin infections post-travel.

Use of electronic medical records to conduct surveillance of malaria among Peace Corps volunteers

Objective

The Peace Corps’ disease surveillance for Peace Corps Volunteers (PCVs) was incorporated into an electronic medical records (EMR) system in 2015. We evaluated this EMR-based surveillance system, focusing particularly on malaria as it is deadly but preventable.

Materials and Methods

In 2016, we administered a survey to Peace Corps Medical Officers (PCMOs), who manage PCVs’ medical care, and semistructured phone interviews to headquarters staff. We assessed the structure of the surveillance system and its utility to stakeholders, evaluated surveillance case definitions for malaria, and compared clinical information in the EMR for malaria cases captured by surveillance during the first half of 2016.

Results

Of 131 PCMOs, 77 (59%) completed the survey. Of 53 respondents in malaria-endemic nations, 98% believed most PCVs contact them about possible malaria. Of 134 cases with a malaria clinical diagnosis in the EMR between January and August 2016, 58 (43% sensitivity) were reported to the surveillance system by PCMOs. The remaining cases in the surveillance system were added during data cleaning, which is time-intensive. Among the 48 malaria cases identified by surveillance between January and June 2016, positive predictive value was 67%.

Discussion

Areas for improvement include streamlining PCMO documentation, refining case definitions, and improving data quality. With such improvements, surveillance data can be used to inform epidemiological analysis, clinical care, health education, and policy.

Conclusion

The EMR is an important tool for malaria surveillance among PCVs and, with the refinements mentioned, could serve as a framework for other multinational organizations to monitor their staff.

New guidelines for the prevention of imported malaria in France

Prevention of malaria is based on personal vector-control measures (PVCMs) to avoid mosquito bites at night and chemoprophylaxis if justified by the risk of contracting the disease. The most effective PVCM is the use of insecticide-treated mosquito nets. The decision to prescribe chemoprophylaxis, mainly to prevent Plasmodium falciparum infection, depends on the benefit-risk ratio. Overall, the risk of contracting malaria is 1,000-fold lower during a stay in the tropical regions of Asia or the Americas than in sub-Saharan Africa. For "conventional" stays (less than one month with nights spent in urban areas) in low-risk settings in tropical Asia and America, the risk of being infected with Plasmodium parasites (≤1/100,000) is equivalent or lower than that of experiencing serious adverse effects caused by chemoprophylaxis. Preventive medication is therefore no longer recommended. By contrast, in other settings and particularly in sub-Saharan Africa, chemoprophylaxis is the most effective measure against malaria. However, it is worth noting that no single preventive measure provides full protection. Regardless of the level of risk or chemoprophylaxis-related indication, protection against mosquito bites and rapid management of febrile illness after returning from an endemic area are also critical to prevent malaria. Finally, migrants of sub-Saharan origin visiting friends and relatives in their country of origin form a high-risk group who should be recommended chemoprophylaxis in the same way as any other travelers-with a preference for the least expensive molecules (doxycycline).

Cutaneous leishmaniasis in non-endemic countries: An emerging yet neglected problem

Cutaneous leishmaniasis (CL) is the most common leishmaniasis syndrome, yet a neglected disease in industrialized non-endemic countries, where it has become an emergent problem. The lack of clinical experience, evidence-based literature and availability of some treatments complicates its management. We report a CL case in a 30 year-old man returned from Brazil, with a cutaneous ulcerated lesion, where it was possible to isolate Leishmania braziliensis/guyanensis complex (subgenus Viannia). An initial course of treatment with miltefosine was attempted, but considering the lack of response, liposomal amphotericin B was used, with very good results. Our report highlights the obstacles faced in the diagnosis and treatment of New World CL in non-endemic countries and the need for more funding and research.

Travelers' diarrhea: update on the incidence, etiology and risk in military and similar populations - 1990-2005 versus 2005-2015, does a decade make a difference?

BACKGROUND

Travelers' diarrhea remains a prevalent illness impacting individuals visiting developing countries, however most studies have focused on this disease in the context of short term travel. This study aims to determine the regional estimates of travelers' diarrhea incidence, pathogen-specific prevalence, and describe the morbidity associated with diarrheal disease among deployed military personnel and similar long term travelers.

METHODS

We updated a prior systematic review to include publications between January 1990 and June 2015. Point estimates and confidence intervals of travelers' diarrhea and pathogen prevalence were combined in a random effects model and assessed for heterogeneity. Eighty-two studies were included in the analysis, including 29 new studies since the prior systematic review.

RESULTS

Military personnel were evaluated in 69% of studies and non-military long term travelers in 34%, with a median duration of travel of 4.9 months, and travel predominantly to the Middle East, Southeast Asia, and Latin America and the Caribbean. Sixty-two percent of tested cases were due to bacterial pathogens, with enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC), and Campylobacter predominating, and significant regional variability. The incidence of TD from studies with longitudinal data was 36.3 cases per 100 person-months, with the highest rates in Southeast Asia, Latin America and the Caribbean, and the Middle East, with higher estimates from those studies using self-reporting of disease. Morbidity remained significant, with 21% being incapacitated or placed sick in quarters (SIQ) by their illness, 15% requiring intravenous fluids, and 3% requiring hospitalization.

CONCLUSIONS

In comparison to results from the prior systematic review, there were no significant differences in incidence, pathogen prevalence, or morbidity; however there was a trend toward improved care-seeking by sick individuals.

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.

Psychological well-being of Portuguese expatriates in Sub-Saharan Africa: a cross-sectional study

BACKGROUND

Psychological health problems are highlighted among the most relevant disease patterns in expatriates. The purpose of this study was to determine the psychological well-being in Portuguese expatriates in Angola and Mozambique, considering the increasing expatriation wave.

METHODS

A cross-sectional self-administered web survey was conducted in a sample of 352 Portuguese civil expatriates in Angola and Mozambique. Clinically significant psychological distress was determined using General Health Questionnaire (GHQ)-12 and associated factors were studied using multiple logistic regression analysis.

RESULTS

GHQ-12 items showed good internal consistency as reflected by the Cronbach's alpha. One-third of the screened expatriates corresponded to cases of clinically significant psychological distress. Age, country of birth, self-reported psychological symptoms and self-perception of general health in the previous 3 months were identified as independent variables associated with psychological distress.

CONCLUSIONS

Increasing awareness and monitoring expatriates mental health should be in the health agenda, furthermore considering them a risk group in need of evidence-based mental health expatriate preparedness. The use of user-friendly validated tools, such as GHQ-12, allowing objective assessment and surveillance of these hard to reach populations should be reinforced.

Review: chronic and persistent diarrhea with a focus in the returning traveler

Background

Travelers’ diarrhea is a common malady afflicting up to 50% of travelers after a 2-week travel period. An appreciable percentage of these cases will become persistent or chronic. We summarized the published literature reporting persistent/chronic diarrhea in travelers elucidating current understanding of disease incidence, etiology and regional variability.

Methods

We searched electronic databases (Medline, Embase, and Cochrane database of clinical trials) from 1990 to 2015 using the following terms: “chronic or persistent diarrh* and (returning) travel* or enteropathogen, GeoSentinel, and travel-associated infection. Included studies published in the English language on adult returning travelers (duration < 3-months) reporting denominator data. Point estimates and standard 95% confidence intervals were calculated for incidence using a random-effects model. Study incidence heterogeneity rates were assessed using x² heterogeneity statistics, graphically represented with Forest plots.

Results

We identified 19 studies meeting the inclusion criteria (all published after 1999). 18 studies reported upon the incidence of persistent/chronic diarrhea as a syndromic diagnosis in returning travelers; one study reported adequate denominator data from which to assess pathogen specific etiology. Giardiasis comprise an appreicaible percentage of infectious mediated persistent/chronic diarrhea in returning travelers. The overall estimate of persistent/chronic diarrhea incidence was 6% (0.05–0.07) in 321,454, travelers; with significant heterogeniety observed across regions. The total number of regional travelers, and point estimates for incidence (95% CI) for Latin American, African, and Asian travelers were [15816 (0.09 [0.07–0.11]), 42290 (0.06 [0.05–0.07]), and 27433 (0.07 [0.06–0.09])] respectively. We identified lower published rates of chronic diarrhea from Sub-Saharan Africa relative to [North Africa, South Central Asia, and Central America]. Persistent/chronic diarrhea ranked fourth as a syndromic diagnosis in all regions.

Conclusions

Persistent/Chronic diarrhea is a leading syndromic diagnosis in returning travelers across all regions. The 6% incidence [proportionate morbidity (PM) of 60] observed in over >300,000 global travelers is comparable to prior estimates. We identified lower published rates of chronic diarrhea from Sub-Saharan Africa relative to [North Africa, South Central Asia, and Central America]. Giardiasis comprises an appreciabile percentatge of travel-associated infectious mediated persistent/chronic diarrhea. There’s a dearth of published data characterizing the incidence of specific enteropathogenic etiologies for persistent/chronic diarrhea in returning travelers.

Pretravel Health Preparation of International Travelers: Results From the Boston Area Travel Medicine Network

Objective

To inform future interventions for advising travelers.

Patients and Methods

We prospectively collected data on travelers seen at the Boston Area Travel Medicine Network, a Boston area research collaboration of 5 travel medicine clinics. Data from 15,440 travelers were collected from March 1, 2008, through July 31, 2010. We compared traveler and trip characteristics and differences in demographic characteristics and travel plans across the 5 clinics, including an analysis of pretravel preparations for certain high-risk destinations.

Results

More than half of the 15,440 travelers were female (8730 [56.5]), and 72.4% (10,528 of 14,545) were white; the median age was 34 years, and 29.4% of travelers (3077 of 10,483) were seen less than 2 weeks before their departure date. Substantial variation in racial background, purpose of travel, and destination risk existed across the 5 clinics. For example, the proportion of travelers visiting friends and relatives ranged from 7.6% (184 of 2436) to 39.0% (1029 of 2639) (18.7% [2876 of 15,360] overall), and the percentage of travelers to areas with malaria risk ranged from 23.7% (333 of 1403) to 52.0% (1306 of 2512). Although most clinics were likely to have prescribed certain vaccines for high-risk destinations (eg, yellow fever for Ghana travel), there was wide variability in influenza vaccine use for China travel.

Conclusion

Substantial differences in clinic populations can occur within a single metropolitan area, highlighting why individual physicians and travel clinics need to understand the specific needs of the travelers they serve in addition to general travel medicine.

Pre-travel health advice guidelines for humanitarian workers: A systematic review

BACKGROUND

In the last decades, there have been several natural disasters and global catastrophies with a steady increase in humanitarian relief work. This has resulted in increased research in the field of humanitarian aid, however the focus is mostly on the victims of the disasters and not on the individuals and organisations providing aid.

OBJECTIVES

The intent of this research is to review the information available on pre-deployment interventions and recommendations such as vaccinations and other health preserving measures in volunteers and professionals deploying abroad in humanitarian relief missions.

METHODS

We performed a systematic literature review of papers written in English, French, Italian or German. We searched the following databases: Cochrane, PubMed, CINAHL, EMBASE and also hand searched reference lists. The cut-off date for the publication search was November 20th, 2014. In addition to the literature search we also sent a questionnaire to 30 organisations to detail their approach to preparing relief workers.

RESULTS

We identified 163 papers of possible relevance and finally included 35 papers in the systematic review. Six organisations provided information on pre-deployment preparation of aid workers. Identified papers show that pre-deployment physical and mental fitness are paramount for success in humanitarian missions. However, in many settings, pre-travel medical and psychological assessments and/or training/education sessions are not mandatory. We identified high-risk hazards for aid workers (often location specific), these included: travellers׳ diarrhoea, vector-borne infections, accidents, violence, tuberculosis, HIV, hepatitis A, leptospirosis, typhoid fever, seasonal and H1N1 influenza.

CONCLUSIONS

The medical evaluation can identify problems or risk factors, such as psychological frailty, that can be exacerbated by the stressful settings of humanitarian missions. In this pre-travel setting, the status of routine vaccinations can be controlled and completed, medication dispensed and targeted preventive advice provided. A mission specific first-aid kit can be recommended. There is a lack of evidence-based literature on the theme of pre-travel advice guidelines for humanitarian workers. We propose a shared database of literature on this topic as a resource and suggest that some standardization of guidelines would be useful for future planning.

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.

Effectiveness of twice a week prophylaxis with atovaquone-proguanil (Malarone®) in long-term travellers to West Africa

BACKGROUND

Current guidelines recommend daily dosing of atovaquone-proguanil (AP), beginning a day before travel to endemic areas and continuing for 7 days after departure. Adherence of long-term travellers to daily malaria chemoprophylaxis tends to be poor, even when residing in highly endemic malaria regions. Evidence from a volunteer challenging study suggests that non-daily, longer intervals dosing of AP provides effective protection against Plasmodium falciparum This study examines the effectiveness of twice weekly AP prophylaxis in long-term travellers to highly endemic P. falciparum areas in West Africa.

METHODS

An observational surveillance study aimed to detect prophylactic failures associated with twice weekly AP, during the years 2013-2014, among long-term expatriates in two sites in West Africa. The expatriates were divided according to the malaria prophylaxis regimen taken: AP twice weekly; mefloquine once weekly and a group refusing to take prophylaxis. Malaria events were recorded for each group. The incidence-density of malaria was calculated by dividing malaria events per number of person-months at risk.

RESULTS

Among 122 expatriates to West Africa the malaria rates were: 11.7/1000 person-months in the group with no-prophylaxis (n = 63); 2.06/1000 person-months in the 40 expatriates taking mefloquine (P = 0.006) and no cases of malaria (0/391 person-months, P = 0.01) in the twice weekly AP group (n = 33).

CONCLUSIONS

No prophylaxis failures were detected among the group of expatriates taking AP prophylaxis twice weekly compared with 11.7/1000 person-months among the no-prophylaxis group. Twice weekly AP prophylaxis may be an acceptable approach for long-term travellers who are unwilling to adhere to malaria chemoprophylaxis guidelines.

Meningococcal vaccination for international travellers from Greece visiting developing countries

BACKGROUND

Meningococcal meningitis is a serious disease. Travel-associated infection for the general traveller is low; however regular epidemics in indigenous population, particularly in sub-Saharan Africa are responsible for significant morbidity and mortality. Our aim was to assess meningococcal vaccination for international travellers from Greece.

METHODS

A prospective questionnaire-based study was conducted during 2009-2013.

RESULTS

A total of 5283 travellers were studied (median age: 39.2 years); Meningococcal tetravalent vaccine (A,C,W135,Y) was delivered to 1150 (21.8%) of them. Of those who travelled to the Middle East and sub-Saharan Africa, 73.1% and 21.2% received meningococcal vaccine, respectively. Of those travellers who travelled to sub-Saharan Africa from November to June and from July to October, 22.1% and 20.6% were vaccinated with meningococcal vaccine, respectively. Of all travellers who travelled for <1 month and ≥1 month, 23.3%, and 20.5%, were vaccinated, respectively. Meningococcal vaccine was administered to 95.3% of pilgrims, 17.4% of those visiting friends and relatives (VFRs), 16.7% of those who travelled for recreation, and 13.8% of those who travelled for work. Of travellers who stayed in urban, in rural, and in urban and rural areas, 32%, 11.6% and 12.7% were vaccinated, respectively. Meningococcal vaccine was delivered to 29.2%, 21.1%, 19.4% and 5.1% of those who stayed in hotels, at local people's home, in camps, and on ships, respectively. The association of meningococcal vaccine administration with the destination, duration and purpose of travel, area of stay and type of accommodation was statistically significant.

CONCLUSION

There is a need to improve meningococcal vaccine recommendations for travellers from Greece, particularly for high risk populations, such as VFRs, business travellers and those visiting sub-Saharan Africa especially during the dry season.

Travel Medical Kit

"The traveler's medical kit is an essential tool for both the novice and expert traveler. It is designed to treat travel-related illness and injury and to ensure preexisting medical conditions are managed appropriately. Travelers are at increased risk for common gastrointestinal issues during travel. Respiratory illnesses make up approximately 8% of the ailments present in returned international travelers. Approximately 12% of travelers experience a travel-related skin condition. First aid treatment for minor injuries is essential to all travel medical kits. The complexity ranges from a small, simple case for the urban traveler to a larger, extensive case for wilderness travel."

Evaluating the A-Subunit of the Heat-Labile Toxin (LT) As an Immunogen and a Protective Antigen Against Enterotoxigenic Escherichia coli (ETEC)

Diarrheal illness contributes to malnutrition, stunted growth, impaired cognitive development, and high morbidity rates in children worldwide. Enterotoxigenic Escherichia coli (ETEC) is a major contributor to this diarrheal disease burden. ETEC cause disease in the small intestine by means of colonization factors and by production of a heat-labile enterotoxin (LT) and/or a small non-immunogenic heat-stable enterotoxin (ST). Overall, the majority of ETEC produce both ST and LT. LT induces secretion via an enzymatically active A-subunit (LT-A) and a pentameric, cell-binding B-subunit (LT-B). The importance of anti-LT antibodies has been demonstrated in multiple clinical and epidemiological studies, and a number of potential ETEC vaccine candidates have included LT-B as an important immunogen. However, there is limited information about the potential contribution of LT-A to development of protective immunity. In the current study, we evaluate the immune response against the A-subunit of LT as well as the A-subunit’s potential as a protective antigen when administered alone or in combination with the B-subunit of LT. We evaluated human sera from individuals challenged with a prototypic wild-type ETEC strain as well as sera from individuals living in an ETEC endemic area for the presence of anti-LT, anti-LT-A and anti-LT-B antibodies. In both cases, a significant number of individuals intentionally or endemically infected with ETEC developed antibodies against both LT subunits. In addition, animals immunized with the recombinant proteins developed robust antibody responses that were able to neutralize the enterotoxic and cytotoxic effects of native LT by blocking binding and entry into cells (anti-LT-B) or the intracellular enzymatic activity of the toxin (anti-LT-A). Moreover, antibodies to both LT subunits acted synergistically to neutralize the holotoxin when combined. Taken together, these data support the inclusion of both LT-A and LT-B in prospective vaccines against ETEC.

Travel-associated disease among US residents visiting US GeoSentinel clinics after return from international travel

BACKGROUND

US residents make 60 million international trips annually. Family practice providers need to be aware of travel-associated diseases affecting this growing mobile population.

OBJECTIVE

To describe demographics, travel characteristics and clinical diagnoses of US residents who present ill after international travel.

METHODS

Descriptive analysis of travel-associated morbidity and mortality among US travellers seeking care at 1 of the 22 US practices and clinics participating in the GeoSentinel Global Surveillance Network from January 2000 to December 2012.

RESULTS

Of the 9624 ill US travellers included in the analysis, 3656 (38%) were tourist travellers, 2379 (25%) missionary/volunteer/research/aid workers (MVRA), 1580 (16%) travellers visiting friends and relatives (VFRs), 1394 (15%) business travellers and 593 (6%) student travellers. Median (interquartile range) travel duration was 20 days (10-60 days). Pre-travel advice was sought by 45%. Hospitalization was required by 7%. Compared with other groups of travellers, ill MVRA travellers returned from longer trips (median duration 61 days), while VFR travellers disproportionately required higher rates of inpatient care (24%) and less frequently had received pre-travel medical advice (20%). Illnesses of the gastrointestinal tract were the most common (58%), followed by systemic febrile illnesses (18%) and dermatologic disorders (17%). Three deaths were reported. Diagnoses varied according to the purpose of travel and region of exposure.

CONCLUSIONS

Returning ill US international travellers present with a broad spectrum of travel-associated diseases. Destination and reason for travel may help primary health care providers to generate an accurate differential diagnosis for the most common disorders and for those that may be life-threatening.

An imported case of cutaneous leishmaniasis caused by Leishmania (Leishmania) donovani in Japan

Leishmaniasis is a major world health problem, and 12 million people are estimated to be infected in 88 countries. There have been few reports of leishmaniasis in Japan and all were of foreign origin; therefore diagnosis is difficult for Japanese physicians. There are 21 different pathogenic Leishmania species, and identification is obtained by polymerase chain reaction (PCR). Here we report an imported case of leishmaniasis by Leishmania (Leishmania) donovani infection from Sri Lanka. L. (L.) donovani usually causes visceral leishmaniasis, but in this case, the patient manifested cutaneous leishmaniasis. The identification of Leishmania species by PCR and investigation of the patient's background such as nationality and disease endemicity are important for diagnosis and treatment. This is the first report of cutaneous leishmaniasis by L. (L.) donovani in Japan.

A profile of travelers--an analysis from a large swiss travel clinic

BACKGROUND

Globally, the Swiss have one of the highest proportions of the population traveling to tropical and subtropical countries. Large travel clinics serve an increasing number of customers with specific pre-travel needs including uncommon destinations and preexisting medical conditions. This study aims to identify health characteristics and travel patterns of travelers seeking advice in the largest Swiss travel clinic so that tailored advice can be delivered.

METHODS

A descriptive analysis was performed on pre-travel visits between July 2010 and August 2012 at the Travel Clinic of the Institute of Social and Preventive Medicine, University of Zurich, Switzerland.

RESULTS

A total of 22,584 travelers sought pre-travel advice. Tourism was the main reason for travel (17,875, 81.5%), followed by visiting friends and relatives (VFRs; 1,715, 7.8%), traveling for business (1,223, 5.6%), and "other reasons" (ie, volunteer work, pilgrimage, study abroad, and emigration; 1,112, 5.1%). The main travel destination was Thailand. In the VFR group, the highest proportions of traveling children (258, 15.1%) and of pregnant or breastfeeding women (23, 3.9%) were observed. Mental disorders were more prominent in VFRs (93, 5.4%) and in travel for "other reasons" (63, 5.7%). The latter stayed for the longest periods abroad; 272 (24.9%) stayed longer than 6 months. VFR travelers received the highest percentage of yellow fever vaccinations (523, 30.5%); in contrast, rabies (269, 24.2%) and typhoid vaccinations (279, 25.1%) were given more often to the "other travel reasons" group.

CONCLUSIONS

New insights into the characteristics of a selected and large population of Swiss international travelers results in improved understanding of the special needs of an increasingly diverse population and, thus, in targeted preventive advice and interventions.

The Pediatric AIDS Corps: a 5-year evaluation

BACKGROUND

The Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children's Hospital created a global health corps named the Pediatric AIDS Corps (PAC) in June 2005. This report provides descriptive details and outputs for PAC over its first 5 years.

METHODS

Demographic data were gathered about PAC physicians employed from July 2006 to June 2011. A 21-question survey was used to query PAC physicians about their experiences in the program. Data concerning clinical experiences and educational programs also were reviewed.

RESULTS

A total of 128 physicians were employed with PAC. The median duration served was 22.7 months. Eighty-seven percent indicated that experience affected their future career choice, with half continuing to work with children and families living in resource-limited areas after they left PAC. Patient care was identified as the most rewarding part of their work (73%), whereas deaths (27%) were the most difficult. Baylor College of Medicine International Pediatric AIDS Initiative enrollment of HIV-infected children and adolescents into care and treatment increased from 6107 to 103 731 with the addition of PAC physicians. Approximately 500 local health care professionals per quarter benefited from HIV clinical attachments that were not available before PAC arrival. PAC physicians visited outreach sites providing in-depth HIV mentoring of local health care professionals, leading to 37% of the sites becoming self-sufficient.

CONCLUSIONS

The positive evaluation by the PAC and the scale-up of clinical and educational programs support the recent calls for the development of a national global health corps program.

Pre-travel preparation of US travelers going abroad to provide humanitarian service, Global TravEpiNet 2009-2011

We analyzed characteristics of humanitarian service workers (HSWs) seen pre-travel at Global TravEpiNet (GTEN) practices during 2009-2011. Of 23,264 travelers, 3,663 (16%) travelers were classified as HSWs. Among HSWs, 1,269 (35%) travelers were medical workers, 1,298 (35%) travelers were non-medical service workers, and 990 (27%) travelers were missionaries. Median age was 29 years, and 63% of travelers were female. Almost one-half (49%) traveled to 1 of 10 countries; the most frequent destinations were Haiti (14%), Honduras (8%), and Kenya (6%). Over 90% of travelers were vaccinated for or considered immune to hepatitis A, typhoid, and yellow fever. However, for hepatitis B, 292 (29%) of 990 missionaries, 228 (18%) of 1,298 non-medical service workers, and 76 (6%) of 1,269 medical workers were not vaccinated or considered immune. Of HSWs traveling to Haiti during 2010, 5% of travelers did not receive malaria chemoprophylaxis. Coordinated efforts from HSWs, HSW agencies, and clinicians could reduce vaccine coverage gaps and improve use of malaria chemoprophylaxis.

Pre-exposure rabies vaccination among US international travelers: findings from the global TravEpiNet consortium

BACKGROUND

People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010.

MATERIAL AND METHODS

We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation.

RESULTS

Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations >6 months versus 1-3 months (adjusted odds ratio [OR]=4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for "research/education" or to "provide medical care" (adjusted OR=5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination.

CONCLUSIONS

Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations.

Wilderness medicine

BACKGROUND

Human activity in wilderness areas has increased globally in recent decades, leading to increased risk of injury and illness. Wilderness medicine has developed in response to both need and interest.

METHODS

The field of wilderness medicine encompasses many areas of interest. Some focus on special circumstances (such as avalanches) while others have a broader scope (such as trauma care). Several core areas of key interest within wilderness medicine are discussed in this study.

RESULTS

Wilderness medicine is characterized by remote and improvised care of patients with routine or exotic illnesses or trauma, limited resources and manpower, and delayed evacuation to definitive care. Wilderness medicine is developing rapidly and draws from the breadth of medical and surgical subspecialties as well as the technical fields of mountaineering, climbing, and diving. Research, epidemiology, and evidence-based guidelines are evolving. A hallmark of this field is injury prevention and risk mitigation. The range of topics encompasses high-altitude cerebral edema, decompression sickness, snake envenomation, lightning injury, extremity trauma, and gastroenteritis. Several professional societies, academic fellowships, and training organizations offer education and resources for laypeople and health care professionals.

CONCLUSIONS

THE FUTURE OF WILDERNESS MEDICINE IS UNFOLDING ON MULTIPLE FRONTS: education, research, training, technology, communications, and environment. Although wilderness medicine research is technically difficult to perform, it is essential to deepening our understanding of the contribution of specific techniques in achieving improvements in clinical outcomes.

Analyzing GeoSentinel surveillance data: a comparison of methods to explore acute gastrointestinal illness among international travelers

GeoSentinel is a global surveillance network of travel medicine clinics that collect data from ill international travelers. Analyses have relied on proportionate morbidity calculations, but proportionate morbidity cannot estimate disease risk because healthy travelers are not included in the denominator. The authors evaluated the use of a case-control design, controlling for GeoSentinel site and date of clinic visit, to calculate a reporting odds ratio (ROR). The association between region of travel and acute gastrointestinal illness was evaluated. All analyses found that the association with acute gastrointestinal illness was greatest among those who traveled to North Africa and South-Central Asia. There was consistency in the magnitude of the ROR and proportionate morbidity ratio (PMR) in regions such as the Caribbean. However, in other regions, the matched ROR was noticeably different than the PMR. The case-control ROR may be preferred for single-disease/syndrome analytical studies using GeoSentinel surveillance data or other surveillance data.

International travel by persons with medical comorbidities: understanding risks and providing advice

OBJECTIVE

To describe the medical conditions, travel plans, counseling, and medications prescribed for high-risk international travelers.

PATIENTS AND METHODS

This cross-sectional study was conducted from March 1, 2008, through July 31, 2010, in 5 clinics in the greater Boston area. We assessed all travelers seen for pretravel care and compared demographic characteristics, travel plans, pretravel counseling, and interventions for healthy and high-risk travelers (as defined by medical history or pregnancy).

RESULTS

Of 15,440 travelers, 2769 (17.9%) were high-risk; 644 of 2769 (23.3%) were immunocompromised travelers, 2056 (74.3%) had medical comorbidities, and 69 (2.5%) were pregnant women. The median age of high-risk travelers was 47 years compared with 32 years for healthy travelers (P=.0001). High-risk travelers visited the clinic a median of 25 days (range, 10-44 days) before departure. Overall, 2562 (93.9%) of high-risk travelers visited countries with medium or high risk of typhoid fever, 2340 (85.7%) visited malaria-risk countries, and 624 (22.8%) visited yellow fever-endemic countries. Of travelers to yellow fever-endemic countries, 8 of 23 (34.8%) pregnant women and 64 of 144 (44.4%) immunocompromised travelers received yellow fever vaccine. Of eligible high-risk travelers, 11 of 76 (14.5%) received a pneumococcal vaccine, 213 of 640 (33.3%) influenza vaccine, and 956 of 2681 (35.7%) either tetanus-diphtheria or tetanus-diphtheria-pertussis vaccine.

CONCLUSION

High-risk travelers made up nearly 20% of patients in these travel clinics, and they mostly traveled to destinations with malaria and typhoid risk. For health care professionals caring for travelers with underlying medical problems, providing appropriate travel counseling and making vaccine decisions, such as for yellow fever, are complex. Travelers with complicated medical histories may warrant evaluation by an experienced travel medicine specialist.

Business travelers: vaccination considerations for this population

Illness in business travelers is associated with reduced productivity on the part of the employee as well as the employer. Immunizations offer a reliable method of preventing infectious diseases for international business travelers. The authors review the travel patterns of business travelers, available data on illnesses they encounter, their potential travel-associated risks for vaccine-preventable diseases and recommendations on immunizations for this population. Routine vaccines (e.g., measles, tetanus and influenza) should be reviewed to assure that they provide current coverage. The combined hepatitis A and hepatitis B vaccine with a rapid schedule offers options for those with time constraints. Other vaccine recommendations for business travelers need to focus on their destinations and activities and underlying health, taking into account the concept of cumulative risk for those with frequent travel, multiple trips or long stays.

Travel-related illness

Travel abroad for business and pleasure should be safe and meaningful for the traveler. To assure that safe experience, certain processes should be considered before travel. A thorough pretravel health assessment will offer patients and health care providers valuable information for anticipatory guidance before travel. The destination-based risk assessment will help determine the risks involved in travel to specific locations and guide in the development of contingency plans for all travelers, especially those with chronic conditions. Diseases are more prevalent overseas, and immunizations and vaccinations are all important considerations for persons traveling abroad.

Travel-related infections in children

Malaria, diarrhea, respiratory infections, and cutaneous larva migrans are common travel-related infections observed in children and adolescents returning from trips to developing countries. Children visiting friends and relatives are at the highest risk because few visit travel clinics before travel, their stays are longer, and the sites they visit are more rural. Clinicians must be able to prepare their pediatric-age travelers before departure with preventive education, prophylactic and self-treating medications, and vaccinations. Familiarity with the clinical manifestations and treatment of travel-related infections will secure prompt and effective therapy.