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Vlot JA, van Steenbergen JE. Hospital-based care and/or death followed by repatriation in Dutch travelers: The HAZARD study. Travel Med Infect Dis 2022; 49:102329. [PMID: 35460875 DOI: 10.1016/j.tmaid.2022.102329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Travelers can experience health problems while abroad. This descriptive study aimed to quantify the disease burden leading to hospital-based care, repatriation or death in Dutch travelers during a stay in a foreign country, including Europe. METHODS Retrospective study of demographic and clinical data from three medical assistance centers (MACs) and the Dutch Ministry of Foreign Affairs on Dutch travelers receiving hospital-based care or who died abroad in the years 2010-2014. Diagnoses were coded according to the International Classification of Diseases (ICD) and classified using the Global Burden of Disease tool. RESULTS Data was available for 77,741 travelers' incidents: 75,385 medical consultations and 2356 deaths. Four in five travelers received inpatient care, of which 36% concerned older travelers (65+) who had significantly longer hospital stays. Overall the top three diagnoses were: injuries (29%), infectious diseases (17%), and cardiovascular diseases (17%). Mental illness was reported in nearly 1.5% of the travelers. Incidence proportions were highest in South-Eastern Asia, with enteric infections as most common diagnosis. Injuries and communicable diseases occurred most often in South-Eastern Asia, while non-communicable diseases were mostly reported in South America. One in five travelers who consulted a physician was repatriated back home, mostly on a scheduled flight with or without medical escort. Cardiovascular diseases and injuries were the leading causes of death. CONCLUSIONS Not only communicable diseases, but also injuries and chronic diseases (in particular cardiovascular diseases) frequently affected travelers' health while staying abroad and frequently necessitated hospital-based care. This should be addressed during the pre-travel counseling.
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Affiliation(s)
- Jessica A Vlot
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Jim E van Steenbergen
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Center for Infectious Disease Control, Netherlands Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, the Netherlands
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Vlot JA, Vive MGD, Brockhoff HJ, van Genderen PJJ, Trompenaars MCE, van Steenbergen JE, Visser LG. Predicting morbidity in older travellers during a short-term stay in the tropics: the ELDEST study. J Travel Med 2021; 28:5991862. [PMID: 33225347 PMCID: PMC7788562 DOI: 10.1093/jtm/taaa216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 11/06/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Older persons may suffer more from travel-related health problems because of ageing and underlying chronic disorders. Knowledge on who is more likely to have these health problems helps to tailor travel health advice more specifically. This study aimed to determine predictors of travel-related morbidity in older travellers by assessing their pre-travel characteristics and performance using physical and cognitive functioning tests. METHODS Multicentre prospective cohort study among older travellers (≥60 years) who consulted one of the participating Dutch travel clinics. Handgrip strength and cognitive performance were measured pre-travel. Participants completed questionnaires before departure and 1 and 4 weeks after return. A diary recorded health complaints during travel until 2-week post-travel. RESULTS In total, 477 travellers completed the study (follow-up rate of 97%). Participants' median age was 66 years. The most visited regions were South-East Asia (34%) and South Asia (14%). Median travel duration was 19 days. Polypharmacy (≥5 medications per day) was not uncommon (16%). The median Charlson Comorbidity Index (CCI) score was 0. Self-reported travel-related infectious diseases concerned primarily respiratory tract infections (21%) and gastroenteritis (10%) whereas non-infectious complaints were injuries (13%), peripheral edema (12%) and dehydration (3%). Medical assistance was sought by 18%, mostly post-travel from their general practitioner (87%). Self-reported physical and mental health-related quality of life significantly improved during and after travel. Predictors for an increased risk of travel-related morbidity were higher CCI score, more travel experience, longer travel duration, higher number of daily medications, visiting northern Africa or South-East and East Asia, and phone and social media use. CONCLUSION Older Dutch travellers are generally fit, well-prepared and suffer not only from common infectious health problems, but also from injuries. Travel improved their self-perceived health. The predictors could be used to identify the more at-risk older traveller and to decrease travel-related morbidity by optimizing pre-travel advice.
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Affiliation(s)
- Jessica A Vlot
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Marissa G D Vive
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henricus J Brockhoff
- Department of Infectious Diseases, Municipal Health Service, Westeinde 128, 2512 HE The Hague, The Netherlands
| | - Pieter J J van Genderen
- Harbour Hospital and Institute for Tropical Diseases, currently working on Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | | | - James E van Steenbergen
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.,Centre for Infectious Disease Control, Netherlands Institute for Public Health and Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, The Netherlands
| | - Leonardus G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Vlot JA, Blanter AI, Jonker EFF, Korse NS, Hack E, Visser LG, Soonawala D. Travel preparation and health risks in Dutch and Belgian medical students during an elective in low- or middle-income countries: A prospective self-reporting cohort study. Travel Med Infect Dis 2020; 37:101779. [PMID: 32590061 DOI: 10.1016/j.tmaid.2020.101779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/21/2020] [Accepted: 05/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Medical schools offer students the opportunity to perform international electives. This study aimed to assess health risks among medical students, to tailor institutional guidelines. METHODS Multicenter study at Dutch and Belgian universities, among medical students who visited low- or middle-income countries. Students completed four questionnaires: once before the elective and two weeks, three- and six months after return. RESULTS Data was complete for 479 students (follow-up rate 84%). Most traveled to Surinam (29%) and South-Africa (14%). Half of the students encountered difficulties in adapting to local culture. Almost 40% visited malaria endemic countries. Nearly all (87%) used chemoprophylaxis as prescribed. Definite needle-stick or splash injuries were reported by 7%. All were dealt with adequately in accordance with national guidelines. However, less than half of 24 possible incidents were handled adequately. Two-and-a-half percent had unprotected sex with a new partner. The incidence of travelers' diarrhea (TD) was 46%. In those with TD, the incidence of post-travel new-onset abdominal complaints was 3%. Three percent were involved in a minor traffic accident, 18% were injured during leisure activities, 5% were threatened or experienced physical violence. Only half of the students visiting a highly endemic country were screened for tuberculosis post-travel. For schistosomiasis this was 6%. CONCLUSIONS Students abroad are exposed to medical and non-medical challenges, which should be addressed during pre-travel counseling. Contact details of a professional back home should be provided, so students can confer in case of problems while abroad. Lastly, we recommend a centrally organized post-travel health check.
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Affiliation(s)
- Jessica A Vlot
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, the Netherlands.
| | - Anastassia I Blanter
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Emile F F Jonker
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Nina S Korse
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Evelien Hack
- Medical School Internationalization Network Netherlands & Flanders, Leiden, the Netherlands
| | - Leonardus G Visser
- Department of Infectious Diseases, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Darius Soonawala
- Department of Nephrology, Leiden University Medical Center (LUMC), Leiden, the Netherlands; Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
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Lääveri T, Vlot JA, van Dam AP, Häkkinen HK, Sonder GJB, Visser LG, Kantele A. Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) among travellers to Africa: destination-specific data pooled from three European prospective studies. BMC Infect Dis 2018; 18:341. [PMID: 30037325 PMCID: PMC6057027 DOI: 10.1186/s12879-018-3245-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 07/09/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND One third of travellers to low- and middle-income regions of the tropics and subtropics become colonized by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). The risk varies by destination and, for each traveller, may be substantially further increased by travellers' diarrhoea (TD) and antibiotic use. Despite the risk of TD in Africa, ESBL-PE acquisition rates in all studies are lower there than in Asia. Africa has become increasingly popular as a destination for international travellers, yet minimal data are available from the continent's subregions and countries. METHODS We analysed subregion- and country-specific data on carriage and risk factors for ESBL-PE colonization pooled from three prospective studies conducted between 2009 and 2013 among Finnish and Dutch travellers. The data were subjected to multivariable analysis of risk factors. In addition, we compared our data to two recent large investigations reporting data by subregion and country. RESULTS Our joint analysis comprised data on 396 travellers. The ESBL-PE colonization rate was highest in Northern Africa, followed by Middle and Eastern Africa, and lowest in Southern and Western Africa. Of individual countries with more than 15 visitors, the highest rates were seen for Egypt (12/17; 70.6%), Ghana (6/23; 26.1%), and Tanzania (14/81; 17.3%); the rates among travellers to Egypt were comparable to those reported in South and Southeast Asia. In a pooled multivariable analysis, travel destination, age, overnight hospitalisation abroad, TD, and use of fluoroquinolones were independently associated with increased ESBL-PE colonization rates. CONLUSIONS Even in areas with relatively low risk of colonization, antimicrobials clearly predispose to colonization with ESBL-PE. Travellers to Africa should be cautioned against unnecessary use of antibiotics.
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Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS,, Helsinki, Finland
| | - Jessica A Vlot
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Alje P van Dam
- Department of Infectious Diseases, Public Health Service (GGD), Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Gerard J B Sonder
- Department of Infectious Diseases, Public Health Service (GGD), Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS,, Helsinki, Finland. .,Clinicum, University of Helsinki, Helsinki, Finland. .,Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland. .,Unit of Infectious Diseases, Karolinska Institutet, Solna, Stockholm, Sweden.
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Paltansing S, Vlot JA, Kraakman MEM, Mesman R, Bruijning ML, Bernards AT, Visser LG, Veldkamp KE. Extended-spectrum β-lactamase-producing enterobacteriaceae among travelers from the Netherlands. Emerg Infect Dis 2014; 19:1206-13. [PMID: 23885972 PMCID: PMC3739527 DOI: 10.3201/eid.1908.130257] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A prospective cohort study was performed among travelers from the Netherlands to investigate the acquisition of carbapenemase-producing Enterobacteriaceae (CP-E) and extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) and associated risk factors. Questionnaires were administered and rectal swab samples were collected and tested before and after traveler return. Of 370 travelers, 32 (8.6%) were colonized with ESBL-E before trave,; 113 (30.5%) acquired an ESBL-E during travel, and 26 were still colonized 6 months after return. No CP-E were found. Independent risk factors for ESBL-E acquisition were travel to South and East Asia. Multilocus sequence typing showed extensive genetic diversity among Escherichia coli. Predominant ESBLs were CTX-M enzymes. The acquisition rate, 30.5%, of ESBL-E in travelers from the Netherlands to all destinations studied was high. Active surveillance for ESBL-E and CP-E and contact isolation precautions may be recommended at admission to medical facilities for patients who traveled to Asia during the previous 6 months.
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Affiliation(s)
- Sunita Paltansing
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.
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Paltansing S, Vlot JA, Kraakman ME, Mesman R, Bruijning ML, Bernards AT, Visser LG, Veldkamp KE. Extended-Spectrum β-Lactamase–producingEnterobacteriaceaeamong Travelers from the Netherlands. Emerg Infect Dis 2013. [DOI: 10.3201/eid1908.130257] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Soonawala D, Vlot JA, Visser LG. Inconvenience due to travelers' diarrhea: a prospective follow-up study. BMC Infect Dis 2011; 11:322. [PMID: 22099542 PMCID: PMC3276490 DOI: 10.1186/1471-2334-11-322] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 11/20/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Limited data exist documenting the degree to which travelers are inconvenienced by travelers' diarrhea (TD). We performed a prospective follow-up study at the travel clinic of Leiden University Medical Center in The Netherlands to determine the degree of inconvenience and to determine how experiencing TD affects travelers' perception. METHODS Healthy adults who intended to travel to the (sub)tropics for less than two months were invited to take part. Participants filled out a web-based questionnaire before departure and after returning home. TD was defined as three or more unformed stools during a 24-hour period. RESULTS 390 of 776 Eligible travelers completed both questionnaires. Participants' median age was 31 years and mean travel duration 23 days. Of 160 travelers who contracted TD (incidence proportion 41%, median duration of TD episode 2.5 days) the majority (107/160, 67%) could conduct their activity program as planned despite having diarrhea. However, 21% (33/160) were forced to alter their program and an additional 13% (20/160) were confined to their accommodation for one or more daylight days; 53 travelers (33%) used loperamide and 14 (9%) an antibiotic. Eight travelers (5%) consulted a physician for the diarrheal illness. When asked about the degree of inconvenience brought on by the diarrheal illness, 39% categorized it as minor or none at all, 34% as moderate and 27% as large or severe. In those who regarded the episode of TD a major inconvenience, severity of symptoms was greater and use of treatment and necessity to alter the activity program were more common. Travelers who contracted travelers' diarrhea considered it less of a problem in retrospect than they had thought it would be before departure. CONCLUSION Conventional definitions of TD encompass many mild cases of TD (in our study at least a third of all cases) for which treatment is unlikely to provide a significant health benefit. By measuring the degree of inconvenience brought on by TD, researchers and policy makers may be able to better distinguish 'significant TD' from mild TD, thus allowing for a more precise estimation of the size of the target population for vaccination or stand-by antibiotic prescription and of the benefit of such measures.
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Affiliation(s)
- Darius Soonawala
- Department of Infectious and Tropical Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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